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DEVOTED CHOICE PREMIUM 010 HI (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE PREMIUM 010 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 010 HI (PPO) in 2026, please refer to our full plan details page.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
DEVOTED CHOICE PREMIUM 010 HI (PPO) is a PPO plan offered by Devoted Health Insurance Company of Hawaii Inc available for the 2026 plan year 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 PREMIUM 010 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 010 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 010 HI (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $49.70. 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 that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6700.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $6700.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $10000.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $10000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
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 010 HI (PPO) plan features a $615 annual drug deductible. Under this plan, Tier 1 preferred generic drugs have no copay for up to a three-month supply at standard pharmacies and through standard mail order. Tier 2 generic drugs carry a $3 copay for a one-month supply, which goes up to $9 at standard pharmacies or a reduced $7.50 for a three-month supply through standard mail order. For brand-name and specialty medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 22% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance. These coinsurance rates apply to both standard retail pharmacy fills and standard mail-order deliveries.
Additional Benefits
The DEVOTED CHOICE PREMIUM 010 HI (PPO) plan offers comprehensive healthcare coverage with no copays for primary care visits, home health services, and annual preventive physicals. For inpatient hospital stays, members pay a $375 daily copay for the first five days, followed by no copay for days six through 90. Specialist visits require a $50 copay, while emergency room visits incur a $130 copay that is waived if admitted. This plan also includes key supplemental benefits, such as dental coverage up to a $1,500 annual limit with no copay for most preventive and comprehensive care. Members receive a $150 annual allowance for eyewear with no copay and a $30 quarterly allowance for over-the-counter items. Routine hearing exams carry a $50 copay, and prescription hearing aids are covered with copays ranging from $199 to $499.
Inpatient Hospital See details
DEVOTED CHOICE PREMIUM 010 HI (PPO) covers inpatient hospital services with no coinsurance, requiring a $375 daily copay for days 1 through 5 and no copay for days 6 through 90 per stay. Unlimited additional days are covered for acute care, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED CHOICE PREMIUM 010 HI (PPO) covers outpatient services with no coinsurance, featuring a $0 to $475 copay for outpatient hospital services and a $375 copay per stay for observation services. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while individual and group outpatient substance abuse sessions require a $50 copay.
Partial Hospitalization See details
DEVOTED CHOICE PREMIUM 010 HI (PPO) covers partial hospitalization services with a $60 copay and no coinsurance. Prior authorization is required for these covered benefits.
Ambulance and Transportation Services See details
DEVOTED CHOICE PREMIUM 010 HI (PPO) covers ambulance services with prior authorization, requiring a $0 to $315 copay and no coinsurance for ground transport, and a 20% coinsurance and no copay for air transport. Transportation services are not covered.
Emergency Services See details
DEVOTED CHOICE PREMIUM 010 HI (PPO) covers emergency services with a $130 copay (waived if admitted within 24 hours) and no coinsurance, and urgently needed services with no copay to a $50 copay and no coinsurance. Worldwide emergency and urgent care are covered up to a $25,000 maximum with a $130 copay and no coinsurance, while worldwide emergency transportation requires a $315 copay and 20% coinsurance.
Primary Care See details
DEVOTED CHOICE PREMIUM 010 HI (PPO) provides primary care physician services with no copay and no coinsurance, while specialist visits, mental health, and physical therapy require a $50 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance for up to 24 routine visits per year (other chiropractic services are not covered), while podiatry services are not covered.
Preventive Services See details
DEVOTED CHOICE PREMIUM 010 HI (PPO) offers partially covered preventive services, with annual physical exams and Medicare-covered preventive care available with no copay and no coinsurance. Some additional preventive services are not covered, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, adult day health, home-based palliative care, in-home support, caregiver support, extra smoking cessation, enhanced disease management, telemonitoring, remote access, and counseling. Other covered benefits like alternative therapies and therapeutic massage have no copay but require up to 50% coinsurance.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE PREMIUM 010 HI (PPO), featuring a $50 copay and no coinsurance for annual routine hearing exams, and a $199 to $499 copay with no coinsurance for up to two prescription hearing aids. There is no deductible for these services, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
DEVOTED CHOICE PREMIUM 010 HI (PPO) provides partially covered vision services, which include one routine eye exam per year with a $0 to $50 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, offering a $150 annual combined maximum benefit for contacts, eyeglasses, frames, lenses, and upgrades.
Dental Services See details
DEVOTED CHOICE PREMIUM 010 HI (PPO) partially covers dental services up to a $1,500 annual maximum for both in- and out-of-network care, though implants, orthodontics, and maxillofacial prosthetics are not covered. Most covered preventive and comprehensive services have no copay and no coinsurance, while restorative, endodontic, and prosthodontic services carry no copay and 0% to 50% coinsurance, and Medicare-covered dental requires a $50 copay and no coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED CHOICE PREMIUM 010 HI (PPO) with no copay and require prior authorization. Associated Medicare Part B chemotherapy and other drugs have no copay and 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CHOICE PREMIUM 010 HI (PPO) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Medical Equipment is partially covered by DEVOTED CHOICE PREMIUM 010 HI (PPO) with no copays for covered services, although diabetic therapeutic shoes and inserts are not covered. Covered durable medical equipment requires a 15% coinsurance, while diabetic supplies incur between no coinsurance and 15% coinsurance, and prosthetic devices and medical supplies range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CHOICE PREMIUM 010 HI (PPO) with no coinsurance for diagnostic services, no copay for lab services and outpatient X-rays, and a copay of $0 to $95 for diagnostic tests. Diagnostic radiological services feature a $0 minimum copay, therapeutic radiological services require a minimum 20% coinsurance, and prior authorization is required.
Home Health Services See details
Home Health Services are covered by DEVOTED CHOICE PREMIUM 010 HI (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered with no coinsurance under the DEVOTED CHOICE PREMIUM 010 HI (PPO) plan, though prior authorization is required. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered and require copays between $25 and $40.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by DEVOTED CHOICE PREMIUM 010 HI (PPO) with no coinsurance, requiring no copay for days 1 through 20 and a $138 daily copay for days 21 through 100. Prior authorization is required and a prior three-day inpatient hospital stay is not needed, though additional days beyond the standard 100 days are not covered.
Other Services See details
DEVOTED CHOICE PREMIUM 010 HI (PPO) provides coverage for select other services, including unlimited acupuncture with no copay and 50% coinsurance, and additional preventive services with no copay and no coinsurance. Additionally, the plan features a $30 quarterly over-the-counter item allowance with no copay and no coinsurance, though meal benefits are not covered.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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