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Devoted CHOICE GIVEBACK Pennsylvania (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE GIVEBACK 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 GIVEBACK Pennsylvania (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE GIVEBACK 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 GIVEBACK 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 GIVEBACK 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 GIVEBACK 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. Additionally, this plan comes with a Part B Premium reduction of $152.70. 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 Pennsylvania (PPO) plan has a $590 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, you'll pay an $8 copay for a preferred generic drug at a standard or mail order pharmacy. In the initial coverage phase, you'll pay these costs until your total drug costs reach $2,000. After this, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs.
Additional Benefits
The Devoted CHOICE GIVEBACK Pennsylvania (PPO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services, and partial hospitalization coverage. Emergency services and ambulance services are also covered, with varying copays and coinsurance. Primary care, preventive services, and services for vision, hearing, and dental are covered with copays, along with home health and skilled nursing facility services. This plan also includes coverage for home infusion bundled services, dialysis services, and durable medical equipment, with varying cost-sharing. Diagnostic and radiological services are covered with copays and coinsurance. Certain services like cardiac rehabilitation, other services, and additional hours of home health care are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with prior authorization. For the first four days of an inpatient stay, the copay is $375, and there is no copay for days 5-90; there is no coinsurance.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $475, Observation Services with a $475 copay, Ambulatory Surgical Center (ASC) Services with no copay, Individual and Group Sessions for Outpatient Substance Abuse with a $45 copay, and Outpatient Blood Services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE GIVEBACK Pennsylvania (PPO) plan, with a $70 copay, and requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE GIVEBACK Pennsylvania (PPO) plan. Ground ambulance services have a copay between $0 and $350, while air ambulance services have a 20% coinsurance, and 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. Emergency Services have a $110 copay, and Urgently Needed Services have a copay between $0 and $45. Worldwide Emergency Transportation has a 20% coinsurance and a $350 copay, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services. Chiropractic Services have a $15 copay, Occupational Therapy Services have a $35 copay, Physician Specialist Services have a $50 copay, Individual and Group Sessions for Mental Health and Psychiatric Services have a $45 copay, Physical Therapy and Speech-Language Pathology Services have a $50 copay, and Opioid Treatment Program Services have a $45 copay. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The Devoted CHOICE GIVEBACK Pennsylvania (PPO) plan covers preventive services, including health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following welcome visits. In-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy (MNT), post-discharge in-home medication reconciliation, readmission 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 routine hearing exams with a $50 copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a copay between $599 and $899, and prescription hearing aids - inner ear, outer ear, and over the ear are not covered.
Vision Services See details
The Devoted CHOICE GIVEBACK Pennsylvania (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, eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with a $50 copay and other dental services with a $250 maximum benefit per year. 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 20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Devoted CHOICE GIVEBACK Pennsylvania (PPO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME) with 19% coinsurance, Prosthetics/Medical Supplies with coinsurance for Medicare-covered devices and supplies, and Diabetic Equipment. Durable Medical Equipment for use outside the home, and 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 procedures, tests, and lab services that ranges from $0 to $95. Lab services have no copay, and diagnostic radiological services have a copay of up to $300. Therapeutic radiological services have a coinsurance of at least 20%, and outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK Pennsylvania (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted CHOICE GIVEBACK Pennsylvania (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization. For days 1-20 and 61-100, there is no copay, and for days 21-60, the copay is $214.
Other Services See details
Other Services are not covered, including acupuncture, over-the-counter items, and meal benefits. Other services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and Case Management are also not covered.
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