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Devoted CHOICE GIVEBACK Hawaii (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE GIVEBACK 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 GIVEBACK Hawaii (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE GIVEBACK 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 GIVEBACK 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 GIVEBACK 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 GIVEBACK 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. Additionally, this plan comes with a Part B Premium reduction of $117.00. You must continue to pay paying your reduced 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 $450.00 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 GIVEBACK Hawaii (PPO) plan has a $450 deductible for prescription drugs. After the deductible is met, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For drugs in the initial coverage phase, you may pay a $1 copay for preferred generic drugs at a standard or mail order pharmacy. Standard generic drugs have a 21% coinsurance, preferred brand drugs have a 25% coinsurance, and non-preferred drugs have a 27% coinsurance. Once your total drug costs reach $2000, you enter the next phase of coverage.
Additional Benefits
The Devoted CHOICE GIVEBACK Hawaii (PPO) plan offers a range of benefits with varying costs. This plan covers inpatient hospital stays with a $375 copay for the first four days and no copay thereafter. Outpatient services, including primary care, have no copays, while specialist visits have a $50 copay. This plan also includes coverage for emergency services, hearing, vision, and dental, with specific copays and annual maximums. Other covered services include home health, skilled nursing, and home infusion, with varying cost-sharing. However, certain services like cardiac rehabilitation, and some additional services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Acute and Psychiatric care. For days 1-4 of Inpatient Hospital-Acute or Inpatient Hospital Psychiatric care, the copay is $375, and there is no copay for days 5-90.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay of $0-$475, observation services with a $375 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with $45 copays for both individual and group sessions. Outpatient blood services are also covered, and this plan waives the three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan with a $70 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan. Ground ambulance services have a copay between $0 and $350, 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 by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan. Emergency Services have a $110 copay, and no coinsurance. Urgently Needed Services have a copay between $0 and $45, and no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, while Worldwide Emergency Transportation has a $350 copay and 20% coinsurance.
Primary Care See details
The Devoted CHOICE GIVEBACK Hawaii (PPO) plan covers Primary Care Physician Services with no copay, Chiropractic Services with a $15 copay, and Occupational Therapy Services with a $35 copay. It also covers Physician Specialist Services with a $50 copay, Mental Health Specialty Services with a $45 copay for individual or group sessions, and Physical Therapy and Speech-Language Pathology Services with a $50 copay. Additional Telehealth Benefits have a copay between $0 and $50, and Opioid Treatment Program Services have a $45 copay. However, Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The Devoted CHOICE GIVEBACK Hawaii (PPO) plan covers preventive services, including annual physical exams, health education, weight management programs, alternative therapies, therapeutic massage, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit. However, in-home safety assessments, personal emergency response systems, 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 are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $45 copay, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams are covered for 1 visit every year. Prescription hearing aids have a copay between $599 and $899 for 2 visits every year, but hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision Services includes coverage for eye exams with a $15 copay, routine eye exams (1 per year), and eyewear, including contact lenses, eyeglasses, eyeglass lenses, and eyeglass frames. Eyewear has a combined maximum benefit of $250 per year.
Dental Services See details
Dental Services are covered, with a $250 annual maximum. Medicare Dental Services require prior authorization and have a $50 copay. Other Dental Services include oral exams, dental x-rays, other diagnostic services, cleaning, fluoride treatments, and other preventive services, all of which are unlimited. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 16% coinsurance and no copay, Prosthetic Devices with 0-20% coinsurance and no copay, and Medical Supplies with a 20% coinsurance and no copay. 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 include coverage for Diagnostic Procedures/Tests with a copay between $0 and $95, Lab Services with no copay, Diagnostic Radiological Services with a copay up to $300, Therapeutic Radiological Services with 20% coinsurance, and Outpatient X-Ray Services with no copay. All services require prior authorization.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan with no copay and no coinsurance. However, Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan. Specifically, Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
The Devoted CHOICE GIVEBACK Hawaii (PPO) plan covers acupuncture with no copay, but does not cover 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, or Self-Directed Personal Assistance Services. Other Services and Other 2 are also covered.
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