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Devoted CHOICE Hawaii (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted 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 CHOICE Hawaii (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE Hawaii (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Maui and Hawaii Counties. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Devoted CHOICE 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 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 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.
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 $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 Hawaii (PPO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For preferred generic drugs, you will pay a $10 copay at standard and mail-order pharmacies. For standard generic and preferred brand drugs, you will pay 25% coinsurance at both standard and mail-order pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Devoted CHOICE Hawaii (PPO) plan offers a range of benefits, including inpatient hospital stays with a $375 copay for the first few days, and outpatient services with varying copays. Emergency and urgent care services are covered, as well as primary care, specialist visits, and mental health services, all with copays. The plan also includes coverage for hearing and vision services, along with dental services up to a $1,000 annual maximum. Additional benefits include coverage for home health services with no copay, diagnostic services, and home infusion. The plan offers coverage for ambulance services, but transportation services are not covered. While the plan covers some services such as cardiac rehabilitation, it does not cover all services. Other services with no copay or coinsurance include acupuncture.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $375 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you will pay a $375 copay for days 1-4, and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered, but additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered by the Devoted CHOICE 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. Outpatient Substance Abuse Services require a $50 copay for both Individual and Group Sessions. Outpatient Blood Services are also covered, including services not usually covered by Medicare plans.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE Hawaii (PPO) plan. You will have a $60 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a copay of $0-$250, while air ambulance services have a 20% coinsurance; transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Devoted CHOICE Hawaii (PPO) plan. Emergency Services has a $125 copay, and Urgently Needed Services has a copay between $0 and $50. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 copay, and Worldwide Emergency Transportation has a $250 copay and 20% coinsurance.
Primary Care See details
The Devoted CHOICE 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 $50 copay, and mental health specialty services with a $50 copay for individual and group sessions. The plan also covers other health care professionals with a $0-$50 copay, psychiatric services with a $50 copay for individual and group sessions, physical therapy and speech-language pathology services with a $0-$50 copay, additional telehealth benefits with a $0-$50 copay, and opioid treatment program services with a $50 copay. Podiatry services are not covered.
Preventive Services See details
Preventive Services are covered, including services not usually covered by Medicare plans, such as Health Education, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Nutritional/Dietary Benefit, Fitness Benefit, Home and Bathroom Safety Devices and Modifications, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. In-Home Safety Assessment, Personal Emergency Response System (PERS), 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, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), and Counseling Services are not covered.
Hearing Services See details
Hearing exams are covered with a $50 copay, and routine hearing exams are covered once per year. Prescription hearing aids are covered with a copay between $399 and $699 twice per year, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision services include coverage for eye exams with a $50 copay, as well as coverage for eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Eyewear has a combined maximum benefit of $1000 per year for both in and out-of-network services.
Dental Services See details
The Devoted CHOICE Hawaii (PPO) plan covers Medicare Dental Services with a $50 copay, and other dental services. The plan has a maximum benefit of $1,000 per year for both in-network and out-of-network services. 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 also covered. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance, while for 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 under the Devoted CHOICE Hawaii (PPO) plan. The coinsurance for these services is between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered by Devoted CHOICE Hawaii (PPO), including Durable Medical Equipment with a coinsurance between 0% and 18%, and Prosthetic Devices with a coinsurance between 0% and 20%. Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered, and Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests, Lab Services, and Radiological Services. Diagnostic Procedures/Tests have a copay of $0 to $95, Lab Services have no copay, Diagnostic Radiological Services have a copay of up to $300, and Therapeutic Radiological Services have a coinsurance of at least 20%, while Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by Devoted CHOICE Hawaii (PPO) with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but the plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. There is a copay for the services that are covered, but the specific amount is not listed.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Devoted CHOICE Hawaii (PPO) with prior authorization required. For days 1-20 and 61-100, there is no copay, while days 21-60 have a $214 copay; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services covered by the Devoted CHOICE Hawaii (PPO) plan include acupuncture with no copay or coinsurance, as well as other services with no copay or coinsurance. 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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