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DEVOTED CHOICE 005 OK (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE 005 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 005 OK (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE 005 OK (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Northeast Oklahoma Area. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE 005 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 005 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 005 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.
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 $375.00 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 $6900.00 (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 $6900.00 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 005 OK (PPO) Medicare plan features an annual prescription drug deductible of $375. For medications in Tier 1 (Preferred Generic) and Tier 2 (Generic), members pay no copay for one-month, two-month, or three-month supplies filled at standard pharmacies or through standard mail order. This makes everyday generic medications highly affordable and accessible under this plan. Higher-tier medications require coinsurance rather than flat copayments during the initial coverage phase. Tier 3 (Preferred Brand) drugs carry a 19% coinsurance, while Tier 4 (Non-Preferred Drug) prescriptions require a 25% coinsurance for standard pharmacy or mail-order fills. Specialty drugs in Tier 5 incur a 28% coinsurance and are limited to a one-month supply.
Additional Benefits
The DEVOTED CHOICE 005 OK (PPO) plan offers affordable coverage for core medical services, featuring no copay for primary care physician visits and a $35 copay for specialists. If you require an inpatient hospital stay, you will pay a $295 daily copay for days 1 through 6, with no copay for days 7 through 90 and no coinsurance. Emergency room visits carry a $130 copay, which is waived upon admission, while urgent care services range from no copay to a $45 copay. For extra care, the plan provides preventive dental services with no copay and comprehensive dental up to a $2,500 yearly limit with 0% to 50% coinsurance. Vision benefits include routine eye exams with no copay to a $35 copay alongside a $300 annual allowance for eyewear, while routine hearing exams require a $35 copay. Members also benefit from a $60 quarterly allowance for over-the-counter items and home health services with no copay.
Inpatient Hospital See details
Inpatient hospital services are covered by DEVOTED CHOICE 005 OK (PPO) with no coinsurance, requiring a $295 daily copay for days 1 through 6 and no copay for days 7 through 90. While unlimited additional acute care days are covered, this benefit is partially covered as psychiatric additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED CHOICE 005 OK (PPO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital services require a copay of $0 to $395, observation services carry a $295 copay per stay, and outpatient substance abuse sessions have a $35 copay, with prior authorization required for these benefits.
Partial Hospitalization See details
Partial hospitalization is covered by DEVOTED CHOICE 005 OK (PPO) with a copay of $105.00 and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered under the DEVOTED CHOICE 005 OK (PPO) plan, though transportation to plan-approved or any health-related locations is not covered. Medicare-covered ground ambulance services require no copay to a $315 copay and no coinsurance, while air ambulance services require a 20% coinsurance and no copay. Prior authorization is required for all ambulance services.
Emergency Services See details
Emergency services under DEVOTED CHOICE 005 OK (PPO) are covered with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services range from no copay to a $45 copay with no coinsurance, while worldwide emergency services are covered up to $25,000 and carry a $130 copay and no coinsurance for emergency or urgent care, and a $315 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE 005 OK (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $35 copay and no coinsurance. Therapy and mental health services require copays ranging from $35 to $50 with no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
DEVOTED CHOICE 005 OK (PPO) offers coverage for preventive services, such as annual physical exams, kidney disease education, and select screenings, with no copay and no coinsurance. Additional preventive benefits are partially covered with no copay and no coinsurance, including fitness programs, alternative therapies, and nutritional counseling, though sub-services like in-home safety assessments, therapeutic massage, and personal emergency response systems are not covered.
Hearing Services See details
Hearing Services are partially covered by DEVOTED CHOICE 005 OK (PPO), featuring a $35 copay and no coinsurance for routine hearing exams, and copays from $399 to $699 with no coinsurance for prescription hearing aids. Under this plan, OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
DEVOTED CHOICE 005 OK (PPO) partially covers vision services with no deductibles, as other eye exam services are not covered. Routine eye exams are covered once per year with a $0 to $35 copay and no coinsurance, while contacts, eyeglasses, and upgrades are covered with no copay and no coinsurance up to a $300 annual maximum.
Dental Services See details
DEVOTED CHOICE 005 OK (PPO) provides partially covered dental services up to a $2,500 yearly maximum, offering preventive care with no copay and no coinsurance, and comprehensive services with no copay and 0% to 50% coinsurance. Medicare-covered dental services require a $35 copay and no coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE 005 OK (PPO) covers home infusion bundled services with no copay, although prior authorization is required. Covered Medicare Part B chemotherapy, insulin, and other drugs require no coinsurance to 20% coinsurance, with insulin also requiring a $35 copay.
Dialysis Services See details
DEVOTED CHOICE 005 OK (PPO) covers Dialysis Services with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
DEVOTED CHOICE 005 OK (PPO) covers medical equipment with no copays, although prior authorization is required. Durable medical equipment carries a 20% to 25% coinsurance, while prosthetics and medical supplies range from no coinsurance to 20% coinsurance. Diabetic equipment is partially covered with no coinsurance to 25% coinsurance for supplies, but diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CHOICE 005 OK (PPO), with prior authorization required for these services. Diagnostic services feature no coinsurance, with no copay for lab services and a copay of $0 to $95 for diagnostic procedures. Radiological services feature no copay for outpatient X-rays and diagnostic radiology, while therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE 005 OK (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by DEVOTED CHOICE 005 OK (PPO) with no coinsurance, but in practice, only some services are covered. Specifically, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for peripheral artery disease (PAD) are not covered, requiring copayments of $25 to $35 and prior authorization.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE 005 OK (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, a prior 3-day hospital stay is not needed before admission, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by DEVOTED CHOICE 005 OK (PPO), offering no copay and no coinsurance for over-the-counter (OTC) items up to $60 every three months and additional preventive services. Acupuncture and meal benefits are not covered under this plan.
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