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Devoted CHOICE GIVEBACK Kentucky (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE GIVEBACK Kentucky (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 Kentucky (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE GIVEBACK Kentucky (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 2025.
It's important to know that Devoted CHOICE GIVEBACK Kentucky (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 Kentucky (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 Kentucky (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 $167.70. 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 $590.00 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 $14000.00 (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 $14000.00 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 Kentucky (PPO) plan has a $590 deductible for prescription drugs. After you meet your deductible, you will pay a copay or coinsurance for your prescriptions, depending on the drug tier and whether you use a preferred or standard pharmacy. For example, in the initial coverage phase, you will pay a $5 copay for preferred generic drugs at a standard or mail order pharmacy. You will pay 25% coinsurance for standard generic, preferred brand, and non-preferred drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Devoted CHOICE GIVEBACK Kentucky (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient hospital services, emergency services, and various primary care services with copays ranging from $0 to $375. The plan also includes coverage for preventive, hearing, vision, and dental services, with specific copays and coverage limits for each. Additional benefits include home health services, skilled nursing facilities, and medical equipment, each with its own cost-sharing structure.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with prior authorization. For Inpatient Hospital-Acute, you will pay a $275 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you will also pay a $275 copay for days 1-5, and no copay for days 6-90. Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $375, observation services with a $275 copay, ambulatory surgical center (ASC) services with no copay, outpatient substance abuse services with a $45 copay for both individual and group sessions, and outpatient blood services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE GIVEBACK Kentucky (PPO) plan, with a $70 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE GIVEBACK Kentucky (PPO) plan, with prior authorization required for all ambulance services. Ground ambulance services have a copay of $0-$300, and air ambulance services have a 20% coinsurance; however, transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Devoted CHOICE GIVEBACK Kentucky (PPO) plan. Emergency Services have a $110 copay, Urgently Needed Services have a $0-$45 copay, and Worldwide Emergency Services have a $110-$300 copay and a 20% coinsurance for Worldwide Emergency Transportation.
Primary Care See details
The Devoted CHOICE GIVEBACK Kentucky (PPO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy, and speech-language pathology services. Chiropractic services have a $15 copay, physician specialist services have a $45 copay, and occupational therapy services have a $35 copay. Mental health services and psychiatric services have a $45 copay for both individual and group sessions. Physical therapy and speech-language pathology services have a copay between $45 and $50. Additional telehealth benefits have a copay between $0 and $45, and opioid treatment program services have a $45 copay.
Preventive Services See details
The Devoted CHOICE GIVEBACK Kentucky (PPO) plan covers preventive services, including Medicare-covered services, annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, kidney disease education, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit. However, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, and counseling services are not covered.
Hearing Services See details
Hearing services include hearing exams with a $45 copay, and routine hearing exams covered once per year. Prescription hearing aids are covered with a copay between $599 and $899, and are limited to 2 per year; however, inner ear, outer ear, and over-the-ear prescription hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
The Devoted CHOICE GIVEBACK Kentucky (PPO) plan covers vision services, including eye exams with a $20 copay. Eyewear is covered with a combined maximum benefit of $250 every year, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $45 copay, as well as other dental services with a $250 annual maximum. Other covered services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and a 20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE GIVEBACK Kentucky (PPO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME) with a 15% coinsurance and no copay, though DME for use outside the home is not covered. Prosthetic Devices are covered with a coinsurance between 0% and 20%, and Medical Supplies have a 20% coinsurance with no copay. Diabetic Equipment is covered, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including Diagnostic Procedures/Tests and Lab Services, are covered. Diagnostic Procedures/Tests have a copay between $0 and $95, while Lab Services have no copay. Radiological Services are covered, with Diagnostic Radiological Services having a copay up to $300 and Therapeutic Radiological Services having a 20% coinsurance, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK Kentucky (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover the sub-services of Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services. The copay information is available below.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20 and 61-100, there is no copay, while days 21-60 have a $214 copay. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Devoted CHOICE GIVEBACK Kentucky (PPO) plan does not cover acupuncture, over-the-counter (OTC) items, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, or Self-Directed Personal Assistance Services. The plan covers other services with no copay.
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