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DEVOTED CHOICE GIVEBACK 009 HI (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 009 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 GIVEBACK 009 HI (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 009 HI (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 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 009 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 GIVEBACK 009 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 GIVEBACK 009 HI (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 $137.00. 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.
This plan has a $605.00 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 GIVEBACK 009 HI (PPO) plan features an annual prescription drug deductible of $605. Under this plan, Tier 1 preferred generic drugs have no copay for one-, two-, or three-month supplies at standard pharmacies or through mail order. Tier 2 generic drugs are available with a low copay starting at $3.00 for a one-month supply, up to a maximum of $9.00 for a three-month standard pharmacy supply. For brand-name and specialty medications, costs are structured as a percentage of the drug cost rather than a flat copay. Tier 3 preferred brand drugs require a 21% coinsurance for standard pharmacy and mail order fills. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance, with specialty medications limited to a one-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 009 HI (PPO) plan offers robust medical coverage featuring no copay for primary care visits and a $55 copay for specialists. Inpatient hospital stays require a $475 daily copay for days one through four, followed by no copay for days five through 90. Additionally, emergency room visits have a $115 copay, which is waived upon admission, while outpatient hospital services range from no copay to a $525 copay. For supplemental care, the plan provides no copay for preventive services and covers routine dental care up to a $250 annual limit with no copay. Routine eye exams range from no copay to a $20 copay, and prescription eyewear is covered with no copay up to a $200 annual limit. Furthermore, there is no copay for skilled nursing facility stays for the first 20 days, and durable medical equipment is available with a 15% coinsurance and no copay.
Inpatient Hospital See details
Inpatient hospital care is covered by DEVOTED CHOICE GIVEBACK 009 HI (PPO) with no coinsurance, requiring a $475 daily copay for days 1 through 4 and no copay for days 5 through 90. While unlimited additional acute care days are covered, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 009 HI (PPO) covers outpatient services with no coinsurance, including outpatient hospital services with a copay of $0 to $525 and observation services with a $475 copay per stay. Ambulatory surgical center and blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions require a $50 copay and no coinsurance.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 009 HI (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance, although prior authorization is required.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 009 HI (PPO) covers ambulance services with prior authorization, featuring no copay to a $350 copay and no coinsurance for ground services, and a 20% coinsurance with no copay for air services. Some transportation services are covered, but transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 009 HI (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with no copay to a $40 copay and no coinsurance. Worldwide emergency and urgent services are covered up to a $25,000 limit with a $115 copay and no coinsurance, while worldwide emergency transportation requires a $350 copay and 20% coinsurance.
Primary Care See details
DEVOTED CHOICE GIVEBACK 009 HI (PPO) provides primary care physician services with no copay and no coinsurance, and specialist visits with a $55 copay and no coinsurance. While therapy, mental health, and psychiatric services require copays of $35 to $55 and no coinsurance, podiatry is not covered, and only some chiropractic services are covered with a $15 copay and no coinsurance, but routine chiropractic care and other chiropractic services are not covered.
Preventive Services See details
DEVOTED CHOICE GIVEBACK 009 HI (PPO) covers preventive services with no copay and no coinsurance, including annual physical exams, kidney education, and glaucoma screenings. Additional preventive services are partially covered, excluding in-home safety assessments, personal emergency response systems, 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
DEVOTED CHOICE GIVEBACK 009 HI (PPO) partially covers hearing services, featuring a $55 copay and no coinsurance for routine exams, and a $599 to $899 copay with no coinsurance for up to two annual prescription hearing aids. OTC hearing aids and inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE GIVEBACK 009 HI (PPO), which includes one routine eye exam per year with a $0 to $20 copay and no coinsurance, though other eye exam services are not covered. Eyewear, including contacts, frames, lenses, and upgrades, is covered with no copay, no coinsurance, and no deductible up to a combined annual maximum of $200.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE GIVEBACK 009 HI (PPO), featuring a $55 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for other covered services up to a $250 annual limit. Maxillofacial prosthetics, implant services, and orthodontics are not covered under this plan.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED CHOICE GIVEBACK 009 HI (PPO) with no copay and require prior authorization. Covered Part B drugs, including chemotherapy and radiation, have no copay and range from no coinsurance to 20% coinsurance, while insulin requires a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 009 HI (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required to receive this benefit.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 009 HI (PPO) partially covers medical equipment with no copays, though prior authorization is required. Covered durable medical equipment carries a 15% coinsurance, while diabetic supplies, prosthetics, and medical supplies range from no coinsurance up to 19% coinsurance. Diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CHOICE GIVEBACK 009 HI (PPO) with no copay for lab services and outpatient X-rays, and no coinsurance for diagnostic tests which carry a $0 to $95 copay. Diagnostic radiological services have copays starting at $0, while therapeutic radiological services require a 20% coinsurance, with prior authorization required.
Home Health Services See details
Home Health Services are covered by the DEVOTED CHOICE GIVEBACK 009 HI (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the DEVOTED CHOICE GIVEBACK 009 HI (PPO) plan, as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all not covered. While the benefit technically features no coinsurance and requires prior authorization, none of these specific services are covered in practice.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) services are covered by DEVOTED CHOICE GIVEBACK 009 HI (PPO) with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20 and a $115 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 009 HI (PPO) offers partial coverage for other services, providing unlimited acupuncture and additional preventive services with no copay and no coinsurance. Over-the-counter (OTC) items and meal benefits are not covered under this plan.
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