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DEVOTED CHOICE GIVEBACK 002 OK (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 002 OK (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 002 OK (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 002 OK (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Oklahoma City. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 002 OK (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 002 OK (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 002 OK (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 $159.90. 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 $13900.00 (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 $13900.00 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 prescription drug coverage for the DEVOTED CHOICE GIVEBACK 002 OK (PPO) plan includes a yearly drug deductible of $605. Under this plan, you will pay no copay for Tier 1 preferred generic drugs at standard pharmacies or through standard mail order. For Tier 2 generic drugs, standard pharmacy copays range from $3.00 for a 1-month supply up to $9.00 for a 3-month supply, while standard mail order offers a discounted 3-month copay of $7.50. For brand-name and specialty medications, costs are based on coinsurance rather than flat copays. 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 restricted to a 1-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 002 OK (PPO) plan offers robust core medical coverage, featuring no copays or coinsurance for primary care visits and covered preventive services. Specialist visits require a $55 copay, while inpatient hospital stays have a $475 daily copay for the first four days followed by no copay for days five through 90. Emergency room visits carry a $115 copay, which is waived if you are admitted within 24 hours, and urgent care copays range from no copay to $40. For routine wellness, the plan provides dental and vision benefits with no copays for most preventive services, including up to a $200 annual allowance for eyewear and a $250 limit on dental care. Routine hearing exams carry a $55 copay, and prescription hearing aids are covered with copays between $599.00 and $899.00. Additionally, skilled nursing facility stays feature no copay for the first 20 days, and home health services are covered with no copay or coinsurance.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 002 OK (PPO) provides partially covered inpatient hospital services with no coinsurance, requiring a $475 daily copay for days 1 through 4 and no copay for days 5 through 90 for acute and psychiatric stays. While unlimited additional acute care days are covered, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED CHOICE GIVEBACK 002 OK (PPO) with no coinsurance, though prior authorization is required for most services. You will pay no copay for ambulatory surgical center or blood services, a $50 copay for substance abuse sessions, a $475 copay per stay for observation services, and a copay ranging from $0 to $475 for outpatient hospital services.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 002 OK (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by DEVOTED CHOICE GIVEBACK 002 OK (PPO), as transportation services to health-related locations are not covered in practice. Covered ground ambulance services require a copay of $0 to $315, while air ambulance services require a 20% coinsurance, with prior authorization required for all ambulance transfers.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 002 OK (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a copay ranging from no copay to $40 and no coinsurance. Worldwide emergency and urgent care are covered up to a $25,000 limit with a $115 copay and no coinsurance, while worldwide emergency transportation requires a $315 copay and 20% coinsurance.
Primary Care See details
DEVOTED CHOICE GIVEBACK 002 OK (PPO) features primary care physician services with no copay and no coinsurance, while specialist visits require a $55 copay and no coinsurance. Covered therapy, mental health, and telehealth services have copays ranging from $0 to $55 with no coinsurance, though podiatry and routine chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered under DEVOTED CHOICE GIVEBACK 002 OK (PPO) with no copay and no coinsurance for all covered care, including annual physicals, fitness benefits, and kidney disease education. However, several sub-services are not covered, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, therapeutic massage, and in-home support services.
Hearing Services See details
DEVOTED CHOICE GIVEBACK 002 OK (PPO) covers routine hearing exams with a $55 copay, no coinsurance, and no deductible. Prescription hearing aids are partially covered with a copay ranging from $599.00 to $899.00 and no coinsurance, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE GIVEBACK 002 OK (PPO), as other eye exam services are not covered, but the plan offers one routine eye exam per year with a $0 to $20 copay and no coinsurance. Eyewear is covered with no copay or coinsurance up to a $200 annual maximum for contacts, eyeglasses, and upgrades.
Dental Services See details
DEVOTED CHOICE GIVEBACK 002 OK (PPO) partially covers dental services, featuring a $55.00 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for most other preventive and comprehensive services up to a $250 annual maximum. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 002 OK (PPO) covers Home Infusion bundled Services with no copay and no coinsurance, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs require a 0% to 20% coinsurance, while Part B insulin has a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 002 OK (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 002 OK (PPO) covers medical equipment with no copay, requiring a 15% coinsurance for durable medical equipment and between no coinsurance and 20% coinsurance for prosthetics and medical supplies. Diabetic equipment is partially covered, offering diabetic supplies with between no coinsurance and 15% coinsurance, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CHOICE GIVEBACK 002 OK (PPO) with prior authorization required, offering no coinsurance for diagnostic services, no copay for lab services, and diagnostic test copays from $0 to $95. Outpatient X-rays have no copay (coinsurance applies), diagnostic radiology has a copay starting at $0, and therapeutic radiology requires a minimum 20% coinsurance.
Home Health Services See details
DEVOTED CHOICE GIVEBACK 002 OK (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 under the DEVOTED CHOICE GIVEBACK 002 OK (PPO) plan with no coinsurance and require prior authorization. While some services are covered, standard cardiac and intensive cardiac rehabilitation (each with a $30 copay), pulmonary rehabilitation (with a $25 copay), and SET for PAD services (with a $20 copay) are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 002 OK (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. You will pay no copay for days 1 through 20 and a $218 copay per day for days 21 through 100; additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by DEVOTED CHOICE GIVEBACK 002 OK (PPO), which offers additional preventive services not covered by Medicare with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered under this plan.
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