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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 Eastern Pennsylvania. 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 $10000.00 (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 $10000.00 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 a $590 deductible for prescription drugs. During the initial coverage phase, after you meet your deductible, your cost sharing will vary based on the drug tier and pharmacy type. For example, you will pay no copay for preferred generic drugs at a standard or mail-order pharmacy. For other tiers, you may pay 25% coinsurance at a standard or mail-order pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you will pay nothing for covered drugs.
Additional Benefits
The Devoted CHOICE Pennsylvania (PPO) plan offers comprehensive coverage, including inpatient and outpatient hospital services with varying copays. You'll find coverage for primary care, preventive services, hearing, vision, and dental, with specific copays for each. The plan also includes coverage for ambulance, emergency services, and home health services, and also covers medical equipment, diagnostic and radiological services, and cardiac rehabilitation. Additional benefits include coverage for partial hospitalization, home infusion, dialysis, and skilled nursing facility services. The plan has a broad range of covered services with the associated costs being copays, coinsurance, or both. However, it is important to note that some services, like certain types of hearing aids, and additional services, are not covered by the plan.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered with prior authorization. For Inpatient Hospital-Acute, you have a $350 copay for days 1-7, and no copay for days 8-90, while Additional Days are covered. For Inpatient Hospital Psychiatric, you have a $350 copay for days 1-5, and no copay for days 6-90; however, Additional Days and Non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services with a copay between $0 and $450, observation services with a $350 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a $40 copay for both individual and group sessions, and outpatient blood services with a waived three-pint deductible. Prior authorization is required for some services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE Pennsylvania (PPO) plan, but requires prior authorization. You will have a $60 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE Pennsylvania (PPO) plan, 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, and transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Services, are covered. Emergency Services have a $110 copay, Urgently Needed Services have a $0-$45 copay, and Worldwide Emergency Transportation has a 20% coinsurance and a $300 copay; Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay.
Primary Care See details
The Devoted CHOICE Pennsylvania (PPO) plan covers 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, Physician Specialist Services have a $40 copay, Occupational Therapy Services have a $35 copay, Individual and Group Mental Health Specialty and Psychiatric Sessions have a $40 copay, Physical Therapy and Speech-Language Pathology Services have a $40-$50 copay, Additional Telehealth Benefits have a $0-$40 copay, and Opioid Treatment Program Services have a $40 copay. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive services include coverage for Medicare-covered preventive services, annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. The plan does not cover in-home safety assessments, personal emergency response systems, medical nutrition therapy, 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, or counseling services.
Hearing Services See details
Hearing Services include routine hearing exams with a $35 copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $399 and $699, but Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered, as well as OTC hearing aids.
Vision Services See details
Vision services include eye exams with a $15 copay, routine eye exams (1 per year), and eyewear coverage with a combined maximum benefit of $1000 per year for both in-network and out-of-network services. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental services include coverage for Medicare dental services with a $40 copay, other dental services, 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. Orthodontic services are covered under Diagnostic and Preventive Dental, with a maximum benefit of $1,000 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 a 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Devoted CHOICE Pennsylvania (PPO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment is covered by the Devoted CHOICE Pennsylvania (PPO) plan, with Durable Medical Equipment (DME) subject to 0-20% coinsurance and Prosthetic Devices subject to 0-20% coinsurance; however, Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. Medical Supplies have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Devoted CHOICE Pennsylvania (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $95, and Lab Services have no copay, while Diagnostic Radiological Services have a maximum copay of $300. Therapeutic Radiological Services have 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 Pennsylvania (PPO) plan, 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 covered, but 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. There is a copay for the covered services, but the amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization, with no copay for days 1-20 and 61-100, and a $214 copay for days 21-60. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Devoted CHOICE Pennsylvania (PPO) plan does not cover acupuncture, over-the-counter (OTC) items, meal benefits, 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, and Self-Directed Personal Assistance Services. Other Services, including $0 Preventive Services, are covered with no copay.
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