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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:
Sign up for Devoted CHOICE Hawaii (PPO)
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Drug Coverage
The Devoted CHOICE Hawaii (PPO) plan has an enhanced alternative drug benefit. The plan has a deductible of $395.00. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, a standard generic drug has a 21% coinsurance. Once your total drug costs reach $2000.00, 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, including inpatient hospital stays with a $325 copay for the first few days, and no copay for many outpatient services. The plan also includes coverage for hearing and vision services, with copays for exams and coverage for hearing aids, eyewear, and other vision needs. This plan provides coverage for dental services, with a $50 copay for Medicare dental and a $1,000 annual maximum for other dental procedures. It also covers ambulance services, emergency services, and home health services.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you'll pay a $325 copay for days 1-5, and no copay for days 6-90; additional days are covered with no copay. Inpatient Hospital Psychiatric has a $325 copay for days 1-4, and no copay for days 5-90; additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient Hospital Services have a copay between $0 and $475, Observation Services have a $325 copay, and Ambulatory Surgical Center (ASC) Services have no copay. Individual and Group Sessions for Outpatient Substance Abuse have a copay between $50 and $50, and Outpatient Blood Services have a three-pint deductible waived.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE Hawaii (PPO) plan, but requires prior authorization. The plan has a $60 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE Hawaii (PPO) plan. Ground ambulance services have a copay between $0 and $250, while air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $125 copay, Urgently Needed Services have a copay between $0 and $50, and Worldwide Emergency Transportation has a $250 copay and 20% coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage both have a $125 copay.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Chiropractic services have a $20 copay. Occupational Therapy Services have a $45 copay. Physician Specialist Services have a copay between $0 and $50. Individual and Group Sessions for Mental Health Specialty Services have a $50 copay. Other Health Care Professional services have a copay between $0 and $50. Individual and Group Sessions for Psychiatric Services have a $50 copay. Physical Therapy and Speech-Language Pathology Services have a $50 copay. Additional Telehealth Benefits have a copay between $0 and $50. Opioid Treatment Program Services have a $50 copay. Podiatry Services are not covered.
Preventive Services See details
The Devoted CHOICE Hawaii (PPO) plan covers preventive services, including no copay for Medicare-covered services, annual physical exams, and other preventive services. Health education, Personal Emergency Response System (PERS), Weight Management Programs, Alternative Therapies, Therapeutic Massage, Nutritional/Dietary Benefit, Fitness Benefit, Home and Bathroom Safety Devices and Modifications, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are covered. However, In-Home Safety Assessment, Medical Nutrition Therapy (MNT), 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 are not covered.
Hearing Services See details
Hearing exams are covered, with a $50 copay for routine hearing exams. Prescription hearing aids (all types) are covered with a copay between $399 and $699, and fitting/evaluation for hearing aids are covered.
Vision Services See details
Under the Devoted CHOICE Hawaii (PPO) plan, vision services include eye exams with a $50 copay, and eyewear with a combined maximum benefit of $1000 per year for both in-network and out-of-network services. The plan also covers contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, with no additional cost-sharing.
Dental Services See details
Devoted CHOICE Hawaii (PPO) covers a $50 copay for Medicare Dental Services, with a $1,000 annual maximum for other dental services. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are all covered, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. The plan has a $35 copay and 20% coinsurance for Medicare Part B Insulin Drugs, and the coinsurance for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Devoted CHOICE Hawaii (PPO) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, Prosthetics/Medical Supplies with a 20% coinsurance, and Diabetic Equipment. Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures and tests with a copay between $0 and $95, and lab services with no copay. Therapeutic Radiological Services have a coinsurance of at most 20%, while Diagnostic Radiological Services have a copay of at most $300. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered under the Devoted CHOICE Hawaii (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered under this plan.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted CHOICE Hawaii (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE Hawaii (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services for the Devoted CHOICE Hawaii (PPO) plan covers acupuncture with no copay, while over-the-counter items, meal benefits, 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, and Self-Directed Personal Assistance Services are not covered. Other Services also covers $0 preventive services.
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