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Devoted LIBERTY CHOICE Hawaii (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted LIBERTY CHOICE Hawaii (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted LIBERTY CHOICE Hawaii (PPO) in 2025, please refer to our full plan details page.
Devoted LIBERTY CHOICE Hawaii (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Hawaii. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Devoted LIBERTY CHOICE Hawaii (PPO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Devoted LIBERTY CHOICE 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 LIBERTY CHOICE 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 $110.00. 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.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $14000.00 (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 $14000.00 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
Prescription drugs are not covered by Devoted LIBERTY CHOICE Hawaii (PPO).
Additional Benefits
The Devoted LIBERTY CHOICE Hawaii (PPO) plan offers comprehensive coverage, including inpatient hospital stays with a copay of $375 for days 1-4, and no copay for days 5-90. Outpatient services have varying copays, and emergency services have a $110 copay. This plan also provides coverage for primary care, hearing, vision, and dental services. Hearing exams have a $45 copay, and prescription hearing aids have a copay between $599 and $899. Vision benefits include eye exams with a $20 copay and an allowance for eyewear. Dental services have a $250 annual maximum with a $45 copay for Medicare dental services.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with a $375 copay for days 1-4 and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered, but non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $475, observation services with a $425 copay, and ambulatory surgical center services with no copay. Additionally, outpatient substance abuse services have a $45 copay for individual and group sessions, and outpatient blood services are covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted LIBERTY CHOICE Hawaii (PPO) plan and requires prior authorization. The copay for this benefit is $70.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted LIBERTY CHOICE Hawaii (PPO) plan. Medicare-covered 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 are covered by the Devoted LIBERTY CHOICE Hawaii (PPO) plan, with a $110 copay and no coinsurance. Urgently Needed Services have a copay between $0 and $45, with no coinsurance. Worldwide Emergency Services are covered with a $110 copay, and Worldwide Emergency Transportation has a $350 copay and 20% coinsurance.
Primary Care See details
The Devoted LIBERTY CHOICE Hawaii (PPO) plan covers primary care physician services, chiropractic services, occupational therapy, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy, speech-language pathology, additional telehealth benefits, and opioid treatment program services. Chiropractic services do not cover routine chiropractic care. Occupational therapy services have a $35 copay, and physician specialist services have a $45 copay. Mental health specialty services, individual sessions, and group sessions all have a $45 copay. Other health care professional services have a copay between $0 and $45. Individual and group psychiatric sessions also have a $45 copay. Physical therapy and speech-language pathology services have a copay between $45 and $50, while additional telehealth benefits have a copay between $0 and $45. Opioid treatment program services have a $45 copay.
Preventive Services See details
The Devoted LIBERTY CHOICE Hawaii (PPO) plan covers preventive services, including Medicare-covered preventive services, annual physical exams, health education, weight management programs, alternative therapies, therapeutic massage, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit. 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 with no copay, and prescription hearing aids. Prescription hearing aids have a copay between $599 and $899, and the plan does not cover prescription hearing aids for the inner ear, outer ear, or over the ear. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $20 copay, and eyewear with a combined maximum of $250 per year for both in-network and out-of-network services. The plan also covers contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
Dental Services are covered, with a $250 annual maximum. Medicare Dental Services require prior authorization and have a $45 copay. Other covered dental services include 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. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 20% coinsurance, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis Services are covered by the Devoted LIBERTY CHOICE Hawaii (PPO) plan. There is a 20% coinsurance for dialysis services.
Medical Equipment See details
Medical equipment is covered by the Devoted LIBERTY CHOICE Hawaii (PPO) plan, with Durable Medical Equipment (DME) requiring a 15% coinsurance and no copay, but excluding coverage for DME for use outside the home. Prosthetic devices have a 0-20% coinsurance and no copay, while medical supplies have a 15% coinsurance and no copay. Diabetic equipment is covered, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Devoted LIBERTY CHOICE Hawaii (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $95, and Lab Services have no copay. Diagnostic Radiological Services have a copay up to $300, and Therapeutic Radiological Services have a 20% coinsurance. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted LIBERTY CHOICE Hawaii (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Devoted LIBERTY CHOICE Hawaii (PPO), but all sub-services are not covered. The plan does not specify any cost sharing information for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. There is no copay for days 1-20, a $214 copay for days 21-60, and no copay for days 61-100.
Other Services See details
The Devoted LIBERTY CHOICE Hawaii (PPO) plan covers acupuncture, with no limitations on the number of treatments. Other services like over-the-counter items, meal benefits, and several other services are not covered by this plan.
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