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Devoted CHOICE Hawaii (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE Hawaii (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted CHOICE Hawaii (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE Hawaii (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Honolulu, Kauai Counties. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Devoted CHOICE Hawaii (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 Hawaii (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 Hawaii (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 $395.00 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 $10000.00 (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 $10000.00 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 Hawaii (PPO) plan has a $395 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you will pay a $1 copay at standard and mail order pharmacies. Standard generic drugs have a 21% coinsurance, while preferred brand drugs have a 25% coinsurance. For non-preferred drugs, you will pay 28% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Devoted CHOICE Hawaii (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $375 copay for the first five days, with no copay for days 6-90. Outpatient services and primary care visits may have copays ranging from $0 to $475, while emergency services have a $125 copay. Preventive, hearing, vision, and dental services are included, with copays for exams and other services. The plan also covers home health services and skilled nursing facilities with no or low copays for the first 20 days, and offers coverage for ambulance, and some medical equipment.
Inpatient Hospital See details
Inpatient Hospital services are covered, with a $375 copay for days 1-5 and no copay for days 6-90 for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. The plan also covers additional days for Inpatient Hospital-Acute, but does not cover Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, or Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with copays ranging from $0 to $475, and observation services with a $375 copay. Ambulatory Surgical Center (ASC) Services have no copay, while outpatient substance abuse services have a $45 copay for both individual and group sessions. Outpatient blood services are also covered, with a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE Hawaii (PPO) plan, with a $60 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Devoted CHOICE Hawaii (PPO), with prior authorization required for all ambulance services. Ground ambulance services have a copay between $0 and $275, while air ambulance services have a 20% coinsurance. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services are covered under Devoted CHOICE Hawaii (PPO), with a $125 copay. Urgently Needed Services are covered with a copay between $0 and $45. Worldwide Emergency Services are also covered, with a $125 copay for Worldwide Emergency Coverage and Worldwide Urgent Coverage, and a $275 copay and 20% coinsurance for Worldwide Emergency Transportation.
Primary Care See details
The Devoted CHOICE Hawaii (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $45 copay, physician specialist services with a $0 - $45 copay, mental health specialty services with a $45 copay, other health care professional services with a $0 - $45 copay, psychiatric services with a $45 copay, physical therapy and speech-language pathology services with a $45 - $50 copay, additional telehealth benefits with a $0 - $45 copay, and opioid treatment program services with a $45 copay. Podiatry services are not covered.
Preventive Services See details
The Devoted CHOICE Hawaii (PPO) plan covers preventive services, including annual physical exams, health education, personal emergency response systems, weight management programs, alternative therapies, therapeutic massage, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. This plan does not cover in-home safety assessments, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, adult day health services, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, and counseling services.
Hearing Services See details
Hearing services include routine hearing exams with a $45 copay. Prescription hearing aids are partially covered, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams, with a $45 copay, eyewear with a combined maximum of $1250 every year, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Routine eye exams are covered once per year.
Dental Services See details
The Devoted CHOICE Hawaii (PPO) plan covers Medicare dental services with a $45 copay and other dental services with a $1,250 maximum benefit per year. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance, while for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Devoted CHOICE Hawaii (PPO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance between 0% and 25% and no copay, and Prosthetic Devices with a coinsurance between 0% and 20% and no copay. Diabetic Equipment is partially covered, with Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts not covered.
Diagnostic and Radiological Services See details
The Devoted CHOICE Hawaii (PPO) plan covers Diagnostic and Radiological Services, including Diagnostic Procedures/Tests with a copay between $0 and $95, and Lab Services with no copay. Radiological Services have a copay up to $300, and Therapeutic Radiological Services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE Hawaii (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Devoted CHOICE Hawaii (PPO) plan, but none of the listed sub-services are covered. The plan mentions that copays apply for cardiac and pulmonary rehabilitation services, but does not specify the amount.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Devoted CHOICE Hawaii (PPO). For days 1-20, there is no copay, and for days 21-100, the copay is $214 per day; additional days beyond Medicare coverage and non-Medicare-covered stays are not covered.
Other Services See details
The Devoted CHOICE Hawaii (PPO) plan covers acupuncture with no copay and no coinsurance, and also covers Other Services benefits like $0 Preventive Services with no copay and no coinsurance. However, the plan does not cover over-the-counter items, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, or Self-Directed Personal Assistance Services.
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