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DEVOTED CHOICE PREMIUM 006 HI (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE PREMIUM 006 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 PREMIUM 006 HI (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE PREMIUM 006 HI (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 2026.
It's important to know that DEVOTED CHOICE PREMIUM 006 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 PREMIUM 006 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 PREMIUM 006 HI (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $53.70. 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 $615.00 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 $10050.00 (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 $10050.00 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 PREMIUM 006 HI (PPO) Medicare plan features an annual drug deductible of $615. Under this plan, you will pay no copay for Tier 1 preferred generic drugs filled at standard pharmacies or through standard mail order. For Tier 2 generic medications, standard copays start at $3.00 for a one-month supply, with standard mail order offering a reduced copay of $7.50 for a three-month supply. Higher-tier medications under this plan require coinsurance rather than flat copays. You will pay 23% coinsurance for Tier 3 preferred brand drugs at standard pharmacies and through standard mail order. Tier 4 non-preferred drugs and Tier 5 specialty drugs both require a 25% coinsurance for standard pharmacy and mail-order services.
Additional Benefits
The DEVOTED CHOICE PREMIUM 006 HI (PPO) plan features no copay and no coinsurance for primary care visits, while specialist visits range from no copay to a $50 copay. For inpatient hospital stays, members pay a $375 daily copay for days 1 through 5 and no copay for days 6 through 90. Emergency room visits require a $130 copay, which is waived if you are admitted to the hospital within 24 hours. Preventive dental care is available with no copay or coinsurance up to a $3,000 annual limit, and routine vision eyewear is covered with no copay up to a $150 yearly maximum. Hearing exams require a $45 copay, with prescription hearing aids covered at copays ranging from $199 to $499 per aid. Additionally, members receive a $30 credit every three months for over-the-counter items with no copay or coinsurance.
Inpatient Hospital See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $375 daily copay for days 1 through 5 and no copay for days 6 through 90. Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers outpatient services with no coinsurance, featuring a $0 to $475 copay for outpatient hospital services and a $375 copay per stay for observation services. Ambulatory surgical center and outpatient blood services are covered with no copay, while outpatient substance abuse individual and group sessions require a $45 copay.
Partial Hospitalization See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers partial hospitalization services with a $60.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers ground ambulance services with a copay ranging from no copay up to $315, and air ambulance services with a 20% coinsurance, with prior authorization required. Transportation services are not covered in practice, as trips to plan-approved or health-related locations are excluded.
Emergency Services See details
Emergency services are covered by DEVOTED CHOICE PREMIUM 006 HI (PPO) 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, while worldwide emergency benefits are covered up to $25,000 and include a 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits, mental health, and therapy services feature copays ranging from $0 to $50 and no coinsurance. Chiropractic services are partially covered with a $15 copay for up to 24 routine visits per year (excluding other chiropractic services), but podiatry services are not covered.
Preventive Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) provides preventive services with no copay and no coinsurance for annual physical exams, kidney disease education, and other standard preventive screenings. Additional preventive benefits are partially covered, featuring alternative therapies and therapeutic massage with 0% to 50% and 50% coinsurance respectively, while sub-services like in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access, and counseling are not covered.
Hearing Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers hearing services, including one annual routine hearing exam for a $45 copay and no coinsurance, and unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $199 to $499 for up to two aids per year, though inner ear, outer ear, over the ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE PREMIUM 006 HI (PPO), offering one routine eye exam per year with a copay ranging from $0 to $45 and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, up to a $150 combined annual maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) offers partially covered dental services up to a $3,000 annual limit, featuring no copay and no coinsurance for preventive care, and no copay with 0% to 50% coinsurance for restorative, endodontic, and prosthodontic services. Medicare-covered dental services require a $45 copay and no coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers home infusion bundled services with no copay, though prior authorization is required and Part D home infusion drugs are not covered. Medicare Part B chemotherapy, radiation, and other drugs require no copay and 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required for this benefit.
Medical Equipment See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers medical equipment with no copays, featuring 20% to 30% coinsurance for durable medical equipment and ranging from no coinsurance to 20% coinsurance for prosthetics and medical supplies. Diabetic equipment is partially covered with diabetic supplies ranging from no coinsurance to 50% coinsurance, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers diagnostic and radiological services, offering no copay and no coinsurance for lab services, diagnostic radiology, and outpatient X-rays. Diagnostic procedures and tests have a copay ranging from $0 to $95 with no coinsurance, while therapeutic radiological services require a 20% coinsurance and a copay, with prior authorization required.
Home Health Services See details
Home Health Services are covered by DEVOTED CHOICE PREMIUM 006 HI (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers cardiac rehabilitation services with no coinsurance and requires prior authorization, but while some services are covered, cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance and does not require a prior three-day hospital stay, though prior authorization is required. There is no copay for days 1 through 20, while days 21 through 100 require a $218 daily copay, with no coverage provided for additional days beyond the Medicare-covered limit.
Other Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) partially covers other services, offering unlimited acupuncture with no copay and 50% coinsurance, and additional preventive services with no copay and no coinsurance. Over-the-counter items are also covered with no copay and no coinsurance up to $30 every three months, while meal benefits are not covered.
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