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DEVOTED CHOICE GIVEBACK 005 HI (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 005 HI (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 005 HI (PPO) in 2026, please refer to our full plan details page.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
DEVOTED CHOICE GIVEBACK 005 HI (PPO) is a PPO plan offered by Devoted Health Insurance Company of Hawaii Inc available for the 2026 plan year to people living in Honolulu, Kauai Counties. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 005 HI (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 005 HI (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 005 HI (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 $119.40. 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 $605.00 drug deductible that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $8300.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $8300.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $10000.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $10000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
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 005 HI (PPO) plan features a $605 annual drug deductible. For Tier 1 preferred generic medications, members pay no copay for one-month, two-month, or three-month fills at standard pharmacies and standard mail order. Tier 2 generic medications are also highly affordable, with standard pharmacy copays ranging from $1.00 for a one-month supply to $3.00 for a three-month supply. For higher-tier medications, costs are determined by coinsurance. Tier 3 preferred brand drugs require a 24% coinsurance across all supply durations at standard pharmacies and standard mail order. Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance, with specialty coverage limited to a one-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 005 HI (PPO) plan offers affordable coverage for essential medical services, featuring no copay and no coinsurance for primary care visits and annual preventive exams. For specialist visits, physical therapy, and urgent care, members will pay moderate copays with no coinsurance. Inpatient hospital stays require a daily copay of $475 for the first four days, followed by no copay for days five through 90. This plan also includes supplemental dental, vision, and hearing benefits, with no copay for routine preventive dental care up to a $250 annual limit and no copay for eyewear up to a $100 annual maximum. For durable medical equipment, dialysis, and certain Part B drugs, members can expect a 20% coinsurance. Additionally, home health services and home infusion bundled therapies are covered with no copay.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 005 HI (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $475 daily copay for days 1 through 4 and no copay for days 5 through 90. Prior authorization is required, and while acute care includes unlimited additional days, upgrades, psychiatric additional days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 005 HI (PPO) covers outpatient hospital services with no coinsurance and copays ranging from $0 to $575, alongside observation services for a $475 copay per stay and no coinsurance. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions have a $50 copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by the DEVOTED CHOICE GIVEBACK 005 HI (PPO) plan with a $70.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 005 HI (PPO) covers ambulance services with prior authorization, offering ground ambulance services with a copay of $0 to $350 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. While some transportation services are covered, transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
Emergency services are covered by DEVOTED CHOICE GIVEBACK 005 HI (PPO) with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed care has no copay to a $40 copay and no coinsurance, while worldwide emergency services are covered up to a $25,000 limit with a $115 copay for medical care and a $350 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
Primary care benefits under the DEVOTED CHOICE GIVEBACK 005 HI (PPO) plan feature no copay and no coinsurance for primary care visits, a $35 copay and no coinsurance for occupational therapy, and a $50 copay and no coinsurance for specialists, physical therapy, and mental health services. Telehealth ranges from no copay to a $50 copay with no coinsurance, podiatry is not covered, and while some chiropractic services are covered, routine and other chiropractic services are not.
Preventive Services See details
Preventive Services under the DEVOTED CHOICE GIVEBACK 005 HI (PPO) plan are covered with no copay and no coinsurance, including annual physicals, kidney disease education, and fitness benefits. While some additional preventive services like therapeutic massage and nutritional counseling are covered, others such as in-home support, telemonitoring, and personal emergency response systems are not covered.
Hearing Services See details
DEVOTED CHOICE GIVEBACK 005 HI (PPO) provides partially covered hearing services, including one annual routine hearing exam for a $50 copay and no coinsurance, alongside unlimited fitting evaluations. Prescription hearing aids are covered up to two per year with a copay ranging from $599 to $899 and no coinsurance, but OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
DEVOTED CHOICE GIVEBACK 005 HI (PPO) offers partially covered vision services, featuring one routine eye exam per year with a $0 to $50 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $100 annual maximum for contacts, eyeglasses, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE GIVEBACK 005 HI (PPO), featuring medicare-covered dental services for a $50 copay and no coinsurance, and other covered preventive and comprehensive services with no copay and no coinsurance up to a $250 annual limit. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED CHOICE GIVEBACK 005 HI (PPO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs have no copay and no coinsurance to 20% coinsurance, while Part B insulin carries a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 005 HI (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 005 HI (PPO) covers medical equipment with no copays, featuring a 20% coinsurance for durable medical equipment (DME) and no coinsurance to 20% coinsurance for prosthetics, medical supplies, and diabetic supplies. Prior authorization is required for these services, and diabetic therapeutic shoes or inserts are not covered under this plan.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 005 HI (PPO) covers diagnostic and radiological services with prior authorization required, featuring no copay for lab services and outpatient X-rays. Diagnostic tests and procedures have no coinsurance and a copay of $0 to $95, while therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE GIVEBACK 005 HI (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE GIVEBACK 005 HI (PPO) provides coverage for some cardiac rehabilitation services with no coinsurance, but specific services including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by DEVOTED CHOICE GIVEBACK 005 HI (PPO) with no coinsurance, requiring no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, a prior three-day inpatient hospital stay is not required for admission, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 005 HI (PPO) partially covers other services, offering unlimited acupuncture and additional preventive services not covered by Medicare with no copay and no coinsurance. Over-the-counter (OTC) items and meal benefits are not covered under this plan.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
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