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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 $47.70. 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 $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 PREMIUM 006 HI (PPO) Medicare plan has an annual prescription drug deductible of $615. For Tier 1 preferred generic medications, you will pay no copay for one-, two-, or three-month supplies at standard pharmacies and mail-order services. Tier 2 generic drugs are also budget-friendly, costing a low $3.00 copay for a one-month supply through standard pharmacies or mail order. For brand-name and specialty prescriptions, costs are based on coinsurance percentages. Tier 3 preferred brand drugs require a 23% coinsurance for standard pharmacy and mail-order fills. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance, helping you plan your out-of-pocket medication expenses.
Additional Benefits
The DEVOTED CHOICE PREMIUM 006 HI (PPO) plan offers comprehensive medical coverage, featuring primary care visits with no copay and specialist visits with a no copay to $60 copay. Inpatient hospital stays require a $400 daily copay for the first five days and no copay for days six through 90, while emergency room visits carry a $130 copay that is waived if admitted. Outpatient services generally feature no coinsurance, though copays vary by service and prior authorizations are often required. For ancillary care, the plan provides dental coverage up to a $1,500 annual limit with no copay for preventive services, alongside an annual $150 allowance for eyewear with no copay. Hearing benefits include routine exams and prescription hearing aids, though copays apply to both. Additionally, members benefit from home health services with no copay and a $30 quarterly allowance for over-the-counter items.
Inpatient Hospital See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) inpatient hospital benefits are partially covered with no coinsurance, requiring a $400 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, though prior authorization is required for most services. There is no copay for ambulatory surgical center and blood services, while outpatient substance abuse sessions require a $60 copay, observation services require a $400 copay per stay, and outpatient hospital services carry a copay ranging from $0 to $500.
Partial Hospitalization See details
Partial hospitalization services are covered by the DEVOTED CHOICE PREMIUM 006 HI (PPO) plan with a $70.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by DEVOTED CHOICE PREMIUM 006 HI (PPO), as transportation to plan-approved or any health-related locations is not covered. Ground ambulance services require a copay ranging from no copay to $315 and no coinsurance, while air ambulance services require a 20% coinsurance and no copay.
Emergency Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require no copay to a $50 copay and no coinsurance, while worldwide emergency services are covered up to $25,000 with a $130 copay and no coinsurance for emergency and urgent care, and a $315 copay with 20% coinsurance for emergency transportation.
Primary Care See details
Primary care benefits under DEVOTED CHOICE PREMIUM 006 HI (PPO) feature primary care physician visits with no copay and no coinsurance, and specialist visits with a $0 to $60 copay and no coinsurance. Most therapy, psychiatric, and telehealth services require a $0 to $60 copay and no coinsurance, though podiatry is not covered and chiropractic care is only partially covered due to the exclusion of other chiropractic services.
Preventive Services See details
Preventive services under the DEVOTED CHOICE PREMIUM 006 HI (PPO) plan, including annual physical exams and kidney disease education, are covered with no copay and no coinsurance. Additional preventive services are partially covered with no copay, featuring coinsurance ranging from no coinsurance to 50% for alternative therapies and therapeutic massage. However, several sub-services are not covered, including in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
Hearing services are partially covered under the DEVOTED CHOICE PREMIUM 006 HI (PPO) plan, offering routine hearing exams for a $60 copay and no coinsurance, though prior authorization is required. Prescription hearing aids are limited to two per year with a copay ranging from $199.00 to $499.00 and no coinsurance, but OTC hearing aids as well as inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) partially covers vision services, offering one routine eye exam per year with a $0 to $60 copay and no coinsurance, though other eye exam services are not covered. Eyewear, including contacts and eyeglasses, is covered with no copay, no coinsurance, and no deductible up to a $150 combined annual maximum benefit.
Dental Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) offers partially covered dental services up to a $1,500 annual limit, with no copay and no coinsurance for preventive care, periodontics, and oral surgery, alongside a $60 copay and no coinsurance for Medicare-covered dental. Restorative, endodontic, and prosthodontic services have no copay and 0% to 50% coinsurance, but 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 and no coinsurance, though prior authorization is required. Under this plan, Medicare Part B chemotherapy, radiation, and other drugs have no copay and 0% to 20% coinsurance, while Part B insulin has a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by DEVOTED CHOICE PREMIUM 006 HI (PPO) with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment carries a 20% to 35% coinsurance, prosthetics and medical supplies range from no coinsurance to 20% coinsurance, and diabetic equipment is partially covered with no coinsurance to 50% coinsurance, excluding diabetic therapeutic shoes and inserts which are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers diagnostic and radiological services with prior authorization required. Diagnostic services have no coinsurance, offering no copay for lab tests and a $0 to $95 copay for procedures, while radiological services feature no copay for X-rays and diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiological services.
Home Health Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by DEVOTED CHOICE PREMIUM 006 HI (PPO) with no coinsurance and require prior authorization. While some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered in practice, carrying copays ranging from $25 to $40.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) covers skilled nursing facility services with no coinsurance and no prior three-day hospital stay requirement. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though prior authorization is required and additional days are not covered.
Other Services See details
DEVOTED CHOICE PREMIUM 006 HI (PPO) partially covers other services, offering acupuncture with no copay and 50% coinsurance, additional preventive services with no copay and no coinsurance, and over-the-counter items with no copay and no coinsurance up to $30 every three months. Meal benefits are not covered.
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