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DEVOTED CHOICE GIVEBACK 006 OK (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 006 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 006 OK (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 006 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 GIVEBACK 006 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 006 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 006 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 $160.00. 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 $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 Devoted Choice Giveback 006 OK (PPO) Medicare plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs are available with no copay for standard pharmacy and standard mail-order fills. Tier 2 generic drugs carry a low copay starting at $3.00 for a 1-month supply, with standard mail-order 3-month supplies costing just $7.50. For higher-tier medications, the plan transitions to coinsurance, with Tier 3 preferred brand drugs requiring a 21% coinsurance for standard pharmacy and mail-order fills. Tier 4 non-preferred drugs and Tier 5 specialty drugs both require a 25% coinsurance, with specialty tier coverage limited to a 1-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 006 OK (PPO) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care visits, home health services, and preventive care. Specialist visits require a copay ranging from $35 to $55, while inpatient hospital stays incur a daily copay of $475 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. This plan also includes essential dental, vision, and hearing benefits to help manage your out-of-pocket costs. You will pay no copay or coinsurance for preventive dental care up to a $250 annual limit, and eyewear is covered up to a $200 yearly maximum with no copay. Routine hearing exams require a $55 copay, and durable medical equipment and dialysis services are covered with a standard 20% coinsurance and no copay.
Inpatient Hospital See details
Inpatient hospital services are covered by DEVOTED CHOICE GIVEBACK 006 OK (PPO) with no coinsurance, requiring a $475 daily copay for days 1 through 4 and no copay for days 5 through 90. Unlimited additional days are covered for acute care, but upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services under the DEVOTED CHOICE GIVEBACK 006 OK (PPO) plan feature no coinsurance across all covered options, with no copays required for ambulatory surgical center and blood services. Outpatient hospital facility visits require a copay of $0 to $575 (with a $475 copay per stay for observation services), and outpatient substance abuse sessions have a $50 copay.
Partial Hospitalization See details
Partial hospitalization is covered by the DEVOTED CHOICE GIVEBACK 006 OK (PPO) plan with a $70.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 006 OK (PPO) covers ambulance services with prior authorization, featuring ground transport with no coinsurance and a copay ranging from no copay to $315, and air transport with a 20% coinsurance and no copay. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 006 OK (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if admitted within 24 hours, and urgently needed services with no copay to a $40 copay and no coinsurance. Worldwide emergency and urgent care are covered up to a $25,000 maximum limit with a $115 copay and no coinsurance, while worldwide emergency transportation incurs a $315 copay and 20% coinsurance.
Primary Care See details
DEVOTED CHOICE GIVEBACK 006 OK (PPO) covers primary care physician services with no copay and no coinsurance, while specialist, occupational therapy, and physical therapy visits require copays ranging from $35 to $55 and no coinsurance. Mental health, psychiatric, and telehealth services are covered with copays up to $55 and no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive Services are covered by DEVOTED CHOICE GIVEBACK 006 OK (PPO) with no copay and no coinsurance, including annual exams, kidney disease education, and select screenings. Additional preventive benefits are partially covered with no copay and no coinsurance, but do not cover in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, re-admission prevention, and wigs. Other excluded services include therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE GIVEBACK 006 OK (PPO), offering routine hearing exams for a $55 copay and no coinsurance, and up to two prescription hearing aids per year with a copay between $599 and $899 and no coinsurance. Over-the-counter (OTC) hearing aids, as well as 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 006 OK (PPO), offering eye exams with a $0 to $55 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $200 annual maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED CHOICE GIVEBACK 006 OK (PPO) offers partially covered dental services with no copay and no coinsurance for preventive and most comprehensive care, up to a $250 annual maximum benefit. Medicare-covered dental services require a $55 copay and no coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 006 OK (PPO) covers home infusion bundled services with no copay, subject to prior authorization. Medicare Part B chemotherapy, radiation, and other drugs are covered with no copay and coinsurance ranging from no coinsurance to 20%, while insulin requires a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 006 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
Medical equipment is partially covered by DEVOTED CHOICE GIVEBACK 006 OK (PPO) with no copays, featuring a 20% coinsurance for durable medical equipment and no coinsurance to 20% coinsurance for prosthetics, medical supplies, and diabetic supplies. Diabetic therapeutic shoes and inserts are not covered under this plan.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 006 OK (PPO) covers diagnostic and radiological services with prior authorization, offering lab services with no copay or coinsurance. Diagnostic tests carry a $0 to $95 copay with no coinsurance, outpatient X-rays require no copay but are subject to coinsurance, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the DEVOTED CHOICE GIVEBACK 006 OK (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE GIVEBACK 006 OK (PPO) covers some Cardiac Rehabilitation Services with no copay and no coinsurance, though standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered in practice.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by DEVOTED CHOICE GIVEBACK 006 OK (PPO), as additional days beyond the standard Medicare-covered limit are not covered. This benefit features no coinsurance, no copay for days 1 through 20, and a $218 copay for days 21 through 100, with prior authorization required and no prior 3-day inpatient hospital stay needed.
Other Services See details
DEVOTED CHOICE GIVEBACK 006 OK (PPO) partially covers other services, providing 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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