A non-government entity
DEVOTED CHOICE 003 OH (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE 003 OH (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED CHOICE 003 OH (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE 003 OH (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Ohio. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that DEVOTED CHOICE 003 OH (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about DEVOTED CHOICE 003 OH (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For DEVOTED CHOICE 003 OH (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $375.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $10100.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $10100.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Devoted Choice 003 OH (PPO) Medicare plan features a $375 annual drug deductible. For Tier 1 preferred generic and Tier 2 generic medications, members enjoy no copay for one-month, two-month, and three-month supplies filled at standard pharmacies or through standard mail order. This ensures that many common prescription drugs are highly accessible and affordable. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 19% coinsurance, while Tier 4 non-preferred drugs have a 25% coinsurance for standard pharmacy and mail order fills. Tier 5 specialty drugs carry a 28% coinsurance for a one-month supply.
Additional Benefits
The DEVOTED CHOICE 003 OH (PPO) plan offers comprehensive medical coverage featuring no copay and no coinsurance for primary care visits, home health services, and preventive care. If you require inpatient hospital stays, you will pay a daily copay of $395 for the first five days and no copay for days six through 90. Specialist visits and emergency services are also covered, requiring copays of $45 to $50 and $130 respectively, with no coinsurance. For supplemental care, this plan includes dental coverage up to a $2,500 annual limit with no copay for preventive services, alongside a $250 annual allowance for eyewear and a $30 quarterly allowance for over-the-counter items. Routine hearing and vision exams are covered with copays ranging up to $45, and prescription hearing aids are available with copays between $399 and $699. Coinsurance is generally not required for these routine services, making your out-of-pocket costs highly predictable.
Inpatient Hospital See details
Inpatient hospital services are covered by DEVOTED CHOICE 003 OH (PPO) with no coinsurance, requiring a $395 daily copay for days 1 through 5 and no copay for days 6 through 90 for both acute and psychiatric stays. Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED CHOICE 003 OH (PPO) with no coinsurance, featuring a $0 to $495 copay for outpatient hospital services and a $395 copay per stay for observation services. Outpatient substance abuse sessions require a $45 copay and no coinsurance, while ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
DEVOTED CHOICE 003 OH (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE 003 OH (PPO) covers ground ambulance services with a copay of $0 to $315 (and no coinsurance) and air ambulance services with a 20% coinsurance (and no copay), both requiring prior authorization. Transportation services to plan-approved or other health-related locations are not covered under this plan.
Emergency Services See details
DEVOTED CHOICE 003 OH (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services range from no copay to a $45 copay with no coinsurance. Worldwide emergency and urgent services are covered up to $25,000, with a $130 copay and no coinsurance for care, and a $315 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE 003 OH (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits, mental health services, and physical therapies require a $45 to $50 copay and no coinsurance. Chiropractic and podiatry services are not covered under this plan.
Preventive Services See details
Preventive services are covered by DEVOTED CHOICE 003 OH (PPO) with no copay and no coinsurance, including annual physical exams, kidney disease education, and other preventive screenings. Additional preventive services are partially covered with no copay and no coinsurance, but do not cover in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy (MNT), post-discharge in-home medication reconciliation, re-admission prevention, wigs for chemotherapy hair loss, therapeutic massage, adult day health services, home-based palliative care, in-home support services, caregiver support, additional smoking cessation counseling, enhanced disease management, telemonitoring, remote access technologies, and counseling services.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE 003 OH (PPO), offering one routine annual exam for a $45 copay and no coinsurance, alongside unlimited fitting evaluations with no copay or coinsurance. Up to two prescription hearing aids are covered per year with no coinsurance and a copay ranging from $399.00 to $699.00, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE 003 OH (PPO), featuring one annual routine eye exam with a copay of $0 to $45 and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay or coinsurance up to a combined limit of $250 per year for contacts, lenses, frames, and upgrades.
Dental Services See details
DEVOTED CHOICE 003 OH (PPO) offers partially covered dental services up to a $2,500 annual limit, featuring no copay and no coinsurance for preventive care, and no copay with 0% to 50% coinsurance for most comprehensive services. Medicare-covered dental services require a $45 copay and no coinsurance, but maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED CHOICE 003 OH (PPO) with no copay and no coinsurance, although prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and insulin, carry a coinsurance ranging from no coinsurance up to 20%, with insulin also requiring a $35 copay.
Dialysis Services See details
Dialysis services are covered by DEVOTED CHOICE 003 OH (PPO) with no copay and a 20% coinsurance. Prior authorization is required to receive these services.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED CHOICE 003 OH (PPO) with no copays for all categories, though coinsurance ranges from 20% to 50% for durable medical equipment, no coinsurance to 20% for prosthetics and medical supplies, and no coinsurance to 50% for diabetic supplies. Prior authorization is required for these benefits, and diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under DEVOTED CHOICE 003 OH (PPO) with prior authorization required. Lab services and outpatient X-rays have no copay, diagnostic tests range from no copay up to a $95 copay with no coinsurance, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE 003 OH (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED CHOICE 003 OH (PPO) with no coinsurance and require prior authorization. While some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered and require copays of $40, $40, $35, and $25 respectively.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE 003 OH (PPO) covers skilled nursing facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day inpatient hospital stay is not necessary, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED CHOICE 003 OH (PPO) partially covers Other Services, offering additional preventive services and over-the-counter (OTC) items with no copay and no coinsurance. Acupuncture and meal benefits are not covered, but the plan features a $30 quarterly allowance for covered OTC items.
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