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Devoted CHOICE PLUS Hawaii (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE PLUS 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 PLUS Hawaii (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE PLUS 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 PLUS 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 PLUS 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 PLUS Hawaii (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $39.00. 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 $590.00 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 $8950.00 (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 $8950.00 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 PLUS Hawaii (PPO) plan has an "Enhanced Alternative" drug benefit type. The plan has a deductible of $590.00. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, you'll pay a $10 copay for preferred generic drugs at a standard pharmacy and 25% coinsurance for standard generic drugs at a standard pharmacy. Once your total drug costs reach $2000.00, you enter the next coverage phase.
Additional Benefits
The Devoted CHOICE PLUS Hawaii (PPO) plan offers comprehensive coverage with varying cost-sharing amounts. Inpatient hospital stays have a copay of $375 for days 1-5, and no copay for days 6-90. Outpatient services, primary care, hearing, and vision services are covered with copays ranging from $0 to $45, while emergency services have a $125 copay. Additional benefits include dental coverage with a maximum annual benefit of $3,000, home health services with no copay, and coverage for hearing aids. The plan also covers ambulance services, diagnostic services, and skilled nursing facility stays. However, some services like cardiac rehabilitation and certain home-based care options are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered. For days 1-5, the copay is $375, and for days 6-90, there is no copay.
Outpatient Services See details
Outpatient Services are covered by the Devoted CHOICE PLUS Hawaii (PPO) plan. Outpatient Hospital Services have a copay between $0 and $475, Observation Services have a $375 copay, and Ambulatory Surgical Center (ASC) Services have no copay. Individual and Group Sessions for Outpatient Substance Abuse have a copay of $45, and Outpatient Blood Services are covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE PLUS Hawaii (PPO) plan, but requires prior authorization. You will have a $60 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE PLUS Hawaii (PPO) plan, with prior authorization required for all ambulance services. Medicare-covered ground ambulance services have a copay of $0 - $275, while air ambulance services have a 20% coinsurance. Transportation services to plan-approved and any health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Devoted CHOICE PLUS Hawaii (PPO) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a copay between $0 and $45. Worldwide Emergency Transportation has a $275 copay and a 20% coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 copay.
Primary Care See details
The Devoted CHOICE PLUS Hawaii (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $0-$45 copay, physician specialist services with a $0-$45 copay, mental health and psychiatric services with a $45 copay for individual and group sessions, physical therapy and speech-language pathology services with a $0-$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
Preventive Services are covered by the Devoted CHOICE PLUS Hawaii (PPO) plan, including Medicare-covered preventive services, annual physical exams, 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, Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. 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, Counseling Services, Enhanced Disease Management, Telemonitoring Services, and Remote Access Technologies are not covered.
Hearing Services See details
Hearing services are covered by the Devoted CHOICE PLUS Hawaii (PPO) plan, including hearing exams with a $45 copay. Prescription hearing aids are covered, with a copay between $199 and $499, for all types of hearing aids, but inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $45 copay, eyewear with a combined maximum benefit of $3,000 per year, and unlimited coverage for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Routine eye exams are covered once per year.
Dental Services See details
Devoted CHOICE PLUS Hawaii (PPO) covers dental services, including a $45 copay for Medicare Dental Services, with a maximum plan benefit of $3,000 per year. 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 covered, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance. For both Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE PLUS Hawaii (PPO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 0-20% coinsurance and no copay, Prosthetic Devices with 0-20% coinsurance and no copay, and Medical Supplies with 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 are covered, including diagnostic procedures and tests with a copay between $0 and $95, and lab services with no copay. Diagnostic radiological services have a copay of up to $300, while therapeutic radiological services have a coinsurance of at least 20%. Outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE PLUS Hawaii (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted CHOICE PLUS Hawaii (PPO) plan. Some services are covered, but the plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
The Devoted CHOICE PLUS Hawaii (PPO) plan covers acupuncture with no copay or coinsurance, and also covers "Other 2" services including $0 preventive services. However, 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.
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