A non-government entity
Devoted CHOICE Pennsylvania (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE Pennsylvania (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted CHOICE Pennsylvania (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE Pennsylvania (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Philadelphia Area. The overall rating for this plan is not yet available for 2025.
It's important to know that Devoted CHOICE Pennsylvania (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 Pennsylvania (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 Pennsylvania (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 $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 $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 Pennsylvania (PPO) plan has an enhanced alternative drug benefit. The plan has a $590 deductible for prescription drugs. During the initial coverage phase, after meeting the deductible, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. For example, you will pay an $8 copay for preferred generic drugs at a standard or mail-order pharmacy. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Devoted CHOICE Pennsylvania (PPO) plan offers a range of benefits, including inpatient hospital stays with a $275 copay for days 1-7, and no copay for days 8-90. The plan also covers outpatient services, emergency services, primary care, preventive services, hearing, vision, dental, home health, and skilled nursing facility services. This plan provides coverage for a variety of services, including ambulance, home infusion, dialysis, medical equipment, and diagnostic and radiological services. Copays, coinsurance, and prior authorization requirements vary depending on the specific service, with some services having no copay and others having a copay or coinsurance. Certain services such as routine chiropractic care, podiatry, and other services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered with prior authorization. For days 1-7, there is a $275 copay, and for days 8-90, there is no copay.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $375, Observation Services with a $275 copay, Ambulatory Surgical Center (ASC) Services with no copay, and Outpatient Substance Abuse Services with a $35 copay for individual and group sessions. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE Pennsylvania (PPO) plan, but requires prior authorization. There is a $60 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a copay between $0 and $300, while air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including urgently needed services and worldwide emergency services, are covered by the Devoted CHOICE Pennsylvania (PPO) plan. For emergency services, there is a $110 copay, and no coinsurance. Urgently needed services have a copay between $0 and $45, with no coinsurance. Worldwide emergency coverage and worldwide urgent coverage have a $110 copay. Worldwide emergency transportation has a $300 copay and 20% coinsurance.
Primary Care See details
The Devoted CHOICE Pennsylvania (PPO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, physician specialist services with a $35 copay, and mental health specialty services with a $35 copay for individual and group sessions. The plan also covers other health care professionals with a $0-$35 copay, psychiatric services with a $35 copay for individual and group sessions, physical therapy and speech-language pathology services with a $35-$50 copay, additional telehealth benefits with a $0-$35 copay, and opioid treatment program services with a $35 copay. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The Devoted CHOICE Pennsylvania (PPO) plan covers preventive services including annual physical exams, health education, personal emergency response systems, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit; however, in-home safety assessment, 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. There are no copays or coinsurance for these services.
Hearing Services See details
Hearing services are covered, including hearing exams with a $35 copay. Prescription hearing aids (all types) are covered with a copay between $399 and $699, but hearing aids for the inner, outer, or over the ear are not covered, nor are OTC hearing aids.
Vision Services See details
Vision Services includes coverage for eye exams with a $35 copay, and also covers eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, with a combined maximum plan benefit coverage of $1000 every year for both in and out-of-network services. Routine eye exams are covered once per year.
Dental Services See details
Devoted CHOICE Pennsylvania (PPO) covers dental services including Medicare dental services with a $35 copay, and also covers 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, with no copay; however, maxillofacial prosthetics, implant services, and orthodontics are not covered. This plan has a $1,000 maximum plan benefit per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. 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 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE Pennsylvania (PPO) plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance of 0-20% and no copay, Prosthetic Devices with a coinsurance of 0-20% and no copay, and Medical Supplies with a 20% coinsurance and no copay; however, Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, with a copay for Medicare-covered diagnostic procedures/tests and lab services. Diagnostic Procedures/Tests have a minimum copay of $0 and a maximum copay of $95, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $300, and Therapeutic Radiological Services have a coinsurance of at most 20%. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by Devoted CHOICE Pennsylvania (PPO), with no copay or coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services are covered. The copay information for some services is available.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE Pennsylvania (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214 per day; additional days beyond Medicare coverage and non-Medicare-covered stays are not covered.
Other Services See details
Other Services are not covered, including acupuncture, over-the-counter (OTC) items, and meal benefits. Additionally, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), and many other services are not covered.
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