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DEVOTED CHOICE GIVEBACK 002 KY (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 002 KY (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 KY (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 002 KY (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Kentucky. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 002 KY (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 KY (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 KY (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 $184.70. 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 002 KY (PPO) prescription drug plan has an annual drug deductible of $605. You will pay no copay for Tier 1 preferred generic drugs filled at standard pharmacies or through standard mail order for up to a three-month supply. For Tier 2 generic drugs, copays start at $3 for a one-month supply, with a three-month supply costing $9 at standard pharmacies and $7.50 through standard mail order. For brand-name and specialty medications, your costs are determined by coinsurance. Tier 3 preferred brand drugs require a 21% coinsurance, while Tier 4 non-preferred drugs require a 25% coinsurance for standard pharmacy and mail order fills. Tier 5 specialty drugs also carry a 25% coinsurance and are limited to a one-month supply.
Additional Benefits
The Devoted Choice Giveback 002 KY (PPO) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care doctor visits, while specialist consultations require a $45 copay. Inpatient hospital stays require a $475 daily copay for the first five days with no copay for subsequent days, and emergency room visits feature a $115 copay. Diagnostic lab tests and home health services are also available with no copay, though durable medical equipment carries a 20% coinsurance. For routine wellness, members enjoy preventive dental care, annual physicals, and fitness programs with no copay. The plan also covers routine vision exams with no copay and provides a $200 annual allowance for eyewear, alongside a $250 allowance for preventive and comprehensive dental services. However, this plan does not cover over-the-counter items, routine chiropractic care, or non-emergency transportation services.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 002 KY (PPO) partially covers inpatient hospital services with no coinsurance, requiring a copay of $475 per day for days 1 to 5 of acute stays (days 1 to 4 for psychiatric) and no copay for subsequent days. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 002 KY (PPO) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and blood services. Outpatient hospital copays range from $0 to $575, observation services cost $475 per stay, and individual or group substance abuse sessions require a $45 copay.
Partial Hospitalization See details
Partial hospitalization services are covered under the DEVOTED CHOICE GIVEBACK 002 KY (PPO) plan with a $70.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Ambulance services are covered by DEVOTED CHOICE GIVEBACK 002 KY (PPO) and require prior authorization, with ground ambulance services carrying a $0 to $320 copay and no coinsurance, and air ambulance services requiring a 20% coinsurance and no copay. Transportation services to plan-approved or any other health-related locations are not covered.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 002 KY (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 no copay to a $40 copay and no coinsurance. Worldwide emergency and urgent services are covered up to a $25,000 maximum benefit, requiring a $115 copay and no coinsurance for care, and a $320 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 002 KY (PPO) provides primary care physician services with no copay and no coinsurance, while specialist visits, mental health, and psychiatric services require a $45 copay and no coinsurance. Physical, occupational, and speech therapies range from a $35 to $50 copay with no coinsurance, whereas chiropractic and podiatry services are not covered.
Preventive Services See details
DEVOTED CHOICE GIVEBACK 002 KY (PPO) preventive services are partially covered with no copay and no coinsurance for covered benefits like annual physical exams, fitness programs, and kidney disease education. However, some additional services are not covered, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, and therapeutic massage.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE GIVEBACK 002 KY (PPO), featuring routine exams for a $45 copay and no coinsurance, and prescription hearing aids with copays ranging from $599 to $899 and no coinsurance. OTC hearing aids, as well as inner ear, outer ear, and over-the-ear prescription hearing aids, are not covered.
Vision Services See details
DEVOTED CHOICE GIVEBACK 002 KY (PPO) features partially covered vision services, including one annual routine eye exam with no copay to a $45 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, providing up to a $200 annual maximum for contacts, lenses, frames, and upgrades.
Dental Services See details
DEVOTED CHOICE GIVEBACK 002 KY (PPO) partially covers dental services, offering Medicare-covered dental for a $45 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.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by DEVOTED CHOICE GIVEBACK 002 KY (PPO) with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, insulin, and other drugs require no coinsurance to 20% coinsurance, with insulin drugs also carrying a $35 copay.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CHOICE GIVEBACK 002 KY (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 002 KY (PPO) partially covers medical equipment with no copays, requiring a 20% coinsurance for durable medical equipment (DME) and no coinsurance to 20% coinsurance for prosthetics, medical supplies, and diabetic supplies. Prior authorization is required for these benefits, and 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 KY (PPO) with prior authorization required. Diagnostic tests and procedures require a copay of $0 to $95 and no coinsurance, lab services require no copay and no coinsurance, and radiological services feature copays starting at $0 with coinsurance applying to X-rays and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE GIVEBACK 002 KY (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED CHOICE GIVEBACK 002 KY (PPO) with no coinsurance, though prior authorization is required. Members will pay a $30 copay for standard and intensive cardiac rehabilitation, a $25 copay for pulmonary rehabilitation, and a $20 copay for supervised exercise therapy (SET) for peripheral artery disease.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by DEVOTED CHOICE GIVEBACK 002 KY (PPO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered under the DEVOTED CHOICE GIVEBACK 002 KY (PPO) plan, which features 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.
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