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DEVOTED CHOICE GIVEBACK 003 CO (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 003 CO (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 003 CO (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 003 CO (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Colorado. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 003 CO (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 003 CO (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 003 CO (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 $169.00. 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 $11300.00 (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 $11300.00 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 003 CO (PPO) prescription drug plan features an annual drug deductible of $605. For Tier 1 preferred generic drugs, members pay no copay for one-, two-, or three-month supplies at standard pharmacies and standard mail order. Tier 2 generic drugs are also highly affordable, requiring a low $3.00 copay for a one-month supply at standard pharmacies or standard mail order. For higher-tier medications, costs are calculated using coinsurance. Members pay a 22% coinsurance for Tier 3 preferred brand drugs and a 25% coinsurance for Tier 4 non-preferred drugs through standard channels. Tier 5 specialty drugs also carry a 25% coinsurance for a one-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 003 CO (PPO) plan offers robust medical coverage with affordable out-of-pocket costs, featuring no copay for primary care doctor visits, home health services, and cardiac rehabilitation. For inpatient hospital stays, members pay a $395 daily copay for days one through five and no copay for days six through 90. Emergency room visits require a $115 copay that is waived upon admission, while urgent care services range from no copay to a $40 copay. Preventive care services, annual physicals, and fitness benefits are fully covered with no copay or coinsurance. The plan also provides routine dental and vision care with no copay up to annual allowance limits, as well as prescription hearing aid coverage with copays between $599 and $899. Other specialized treatments, such as dialysis and durable medical equipment, are covered with a 20 percent coinsurance.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 003 CO (PPO) covers inpatient hospital services with no coinsurance, requiring a $395 daily copay for days 1 through 5 and no copay for days 6 through 90 for both acute and psychiatric stays. This benefit is partially covered as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 003 CO (PPO) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and blood services. Outpatient hospital services require a copay of $0 to $495 (or $395 per stay for observation services), and outpatient substance abuse sessions carry a $50 copay.
Partial Hospitalization See details
Partial hospitalization services are covered by DEVOTED CHOICE GIVEBACK 003 CO (PPO) with a $70.00 copay and no coinsurance. Prior authorization is required to receive these covered services.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 003 CO (PPO) covers ambulance services with prior authorization, featuring ground ambulance services with a copay ranging from no copay to $350 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Transportation services are not covered under this plan.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 003 CO (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no copay to a $40 copay and no coinsurance, while worldwide emergency services are covered up to $25,000 with copays up to $350 and 20% coinsurance for transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 003 CO (PPO) provides primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, and psychiatric services require a $50 copay and no coinsurance. Occupational therapy is covered with a $35 copay and no coinsurance, chiropractic services are partially covered with a $15 copay and no coinsurance (routine and other chiropractic services are not covered), and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by DEVOTED CHOICE GIVEBACK 003 CO (PPO) with no copay and no coinsurance for covered care such as annual physicals, fitness benefits, and kidney disease education. However, this benefit does not cover in-home safety assessments, personal emergency response systems (PERS), 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 counseling, enhanced disease management, telemonitoring, remote access technologies, or counseling services.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE GIVEBACK 003 CO (PPO), featuring routine hearing exams with a $50 copay and no coinsurance, and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are covered with a copay ranging from $599 to $899 and no coinsurance, though OTC hearing aids alongside inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE GIVEBACK 003 CO (PPO), offering one routine eye exam per year with a $0 to $50 copay (prior authorization required), no coinsurance, and no deductible, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, up to a $200 annual maximum for contacts, eyeglasses, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE GIVEBACK 003 CO (PPO), featuring Medicare-covered dental services for a $50 copay and no coinsurance, and other covered preventive and comprehensive services with no copay and no coinsurance up to a $250 annual maximum. 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 003 CO (PPO) with no copay, though prior authorization and step therapy may apply. Associated Medicare Part B chemotherapy, radiation, and other drugs carry a coinsurance ranging from no coinsurance to 20%, while Part B insulin requires a $35 copay and up to 20% coinsurance.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 003 CO (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required to receive this covered benefit.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED CHOICE GIVEBACK 003 CO (PPO) with no copays, but prior authorization is required for all services. Durable medical equipment incurs a 20% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance to 20% coinsurance; however, diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under DEVOTED CHOICE GIVEBACK 003 CO (PPO), with prior authorization required for both. Diagnostic services require no coinsurance, featuring no copay for lab tests and a $0 to $95 copay for procedures, while radiological services carry a minimum 20% coinsurance for therapeutic radiology, a copay starting at $0 for diagnostic radiology, and no copay for outpatient X-rays.
Home Health Services See details
Home health services are covered by DEVOTED CHOICE GIVEBACK 003 CO (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the DEVOTED CHOICE GIVEBACK 003 CO (PPO) plan with no copay and no coinsurance, though prior authorization is required. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 003 CO (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior three-day hospital stay requirement, though prior authorization is required. There is no copay for days 1 through 20 and a $218 copay per day for days 21 through 100, while additional days beyond the standard Medicare-covered period are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 003 CO (PPO) partially covers other services, offering 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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