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DEVOTED CHOICE GIVEBACK 003 PA (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 003 PA (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 PA (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 003 PA (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Philadelphia Area. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 003 PA (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 PA (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 PA (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 003 PA (PPO) prescription drug plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs are covered with no copay for one-, two-, or three-month supplies at standard pharmacies and standard mail order. Tier 2 generic drugs are also highly affordable, starting at a low $3 copay for a one-month supply at standard pharmacies and standard mail-order services. For higher-tier medications, this Medicare plan utilizes coinsurance rather than flat copays. Members pay a 22% coinsurance for Tier 3 preferred brand drugs, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance. These cost-sharing rates apply consistently across both standard retail pharmacies and standard mail-order deliveries.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 003 PA (PPO) plan offers robust coverage for essential medical services, featuring no copay or coinsurance for primary care doctor visits, annual physical exams, and home health services. For specialist visits, physical therapy, and mental health services, members pay a direct $50 copay with no coinsurance. Inpatient hospital stays require a $475 daily copay for the first four days followed by no copay for days five through 90, while emergency room visits carry a flat $115 copay that is waived if you are admitted. Additional benefits include dental coverage with no copay up to a $250 annual limit, an eyewear allowance of up to $200 with no copay, and hearing aid coverage with copays ranging from $599 to $899. Diagnostic lab work, outpatient X-rays, and diagnostic radiological services are also available with no copay. Additionally, the plan features a quarterly $91 allowance for over-the-counter items with no copay, and skilled nursing facility stays are covered with no copay for the first 20 days.
Inpatient Hospital See details
Inpatient hospital care is covered by DEVOTED CHOICE GIVEBACK 003 PA (PPO) with no coinsurance, requiring a $475 daily copay for days 1 through 4 and no copay for days 5 through 90 for both acute and psychiatric stays. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional days for psychiatric stays are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 003 PA (PPO) covers outpatient services with no coinsurance, although prior authorization is required for these benefits. Outpatient hospital services have a copay of $0 to $575, observation services require a $475 copay per stay, and substance abuse sessions have a $50 copay, while ambulatory surgical center and blood services are available with no copay.
Partial Hospitalization See details
Partial hospitalization services are covered by the DEVOTED CHOICE GIVEBACK 003 PA (PPO) plan with a $70.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 003 PA (PPO) covers ambulance services with prior authorization, requiring a copay of up to $350 (with no copay for some trips) and no coinsurance for ground transport, and a 20% coinsurance with no copay for air transport. For transportation services, some services are covered but trips to plan-approved or any health-related locations are not covered.
Emergency Services See details
Emergency services are covered under the DEVOTED CHOICE GIVEBACK 003 PA (PPO) plan with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, while urgently needed care carries a copay ranging from no copay to $40 and no coinsurance. Worldwide emergency and urgent care are covered up to a $25,000 limit with a $115 copay and no coinsurance, though worldwide emergency transportation requires a $350 copay and 20% coinsurance.
Primary Care See details
DEVOTED CHOICE GIVEBACK 003 PA (PPO) features primary care physician services with no copay and no coinsurance, while specialist, mental health, and physical therapy services require a $50 copay and no coinsurance. Occupational therapy has a $35 copay and no coinsurance, podiatry is not covered, and chiropractic services are partially covered with routine chiropractic care excluded.
Preventive Services See details
Preventive services are partially covered by DEVOTED CHOICE GIVEBACK 003 PA (PPO) with no copay and no coinsurance for covered benefits like annual physical exams, fitness programs, and kidney disease education. However, several sub-services are not covered, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, and therapeutic massage.
Hearing Services See details
DEVOTED CHOICE GIVEBACK 003 PA (PPO) covers hearing exams and fitting evaluations with no coinsurance, featuring a $50 copay for routine exams and no copay for fittings. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $599 to $899, while inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE GIVEBACK 003 PA (PPO), featuring one annual routine eye exam with a $0 to $50 copay, 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 combined annual limit of $200 for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED CHOICE GIVEBACK 003 PA (PPO) dental services are partially covered, featuring no copay and no coinsurance for most diagnostic, preventive, and restorative services up to a $250 annual limit, though implants, orthodontics, and maxillofacial prosthetics are excluded. Medicare-covered dental services require a $50 copay and no coinsurance.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 003 PA (PPO) covers home infusion bundled services with no copay, subject to prior authorization. Covered Medicare Part B insulin requires a $35 copay and coinsurance ranging from no coinsurance up to 20%, while other Part B chemotherapy, radiation, and biological drugs require coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Dialysis Services are covered by DEVOTED CHOICE GIVEBACK 003 PA (PPO) with no copay and a 20% coinsurance, and prior authorization is required.
Medical Equipment See details
Medical Equipment benefits under DEVOTED CHOICE GIVEBACK 003 PA (PPO) are partially covered with no copays, though prior authorization is required for these services. Durable medical equipment carries a 20% coinsurance, while prosthetic devices, medical supplies, and diabetic supplies require no coinsurance to 20% coinsurance; 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 PA (PPO), featuring no coinsurance for diagnostic services, no copay for lab services and outpatient X-rays, and a copay ranging from $0 to $95 for diagnostic procedures and tests. Diagnostic radiological services have no copay, while therapeutic radiological services carry a 20% coinsurance, and prior authorization is required for these benefits.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE GIVEBACK 003 PA (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered with no coinsurance under the DEVOTED CHOICE GIVEBACK 003 PA (PPO) plan, but in practice, some services are covered while cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) services are not covered. These non-covered sub-services require prior authorization and carry copays ranging from $20.00 to $30.00.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 003 PA (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior 3-day hospital stay required, though prior authorization is necessary. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, while additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 003 PA (PPO) partially covers other services, offering additional preventive services and up to $91 every three months for over-the-counter items with no copay and no coinsurance. Acupuncture, meal benefits, and other unspecified services are not covered under this benefit.
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