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 Western 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 $11000.00 (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 $11000.00 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:
Sign up for Devoted CHOICE Pennsylvania (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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, you'll pay varying costs depending on the drug tier and pharmacy. For example, you'll pay a $5 copay for preferred generic drugs at a standard or mail-order pharmacy, and 25% coinsurance for standard generic, preferred brand, and non-preferred drugs. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you will pay nothing for your Part D covered drugs. If you qualify for the low-income subsidy, you will pay no cost for your drugs.
Additional Benefits
The Devoted CHOICE Pennsylvania (PPO) plan offers a wide range of benefits, including inpatient and outpatient hospital services, with varying copays. You'll have no copay for many services, such as outpatient ambulatory surgical center services, home health services, and lab services. Emergency, primary care, preventive, vision, hearing, and dental services are also covered, with copays and coinsurance applying to some services. Additional benefits include coverage for ambulance, partial hospitalization, dialysis, home infusion, and medical equipment. Other services like cardiac rehabilitation, skilled nursing facility, and diagnostic and radiological services are covered, with some requiring prior authorization or having specific copays and coinsurance. However, certain services such as acupuncture, over-the-counter items, and personal care services are not covered by this plan.
Inpatient Hospital See details
Inpatient Hospital services, including Acute and Psychiatric, are covered, with a copay of $345 for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient hospital services have a copay between $0 and $445, observation services have a $345 copay, individual and group sessions for outpatient substance abuse have a $30 copay, and ambulatory surgical center services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You will pay 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. Ground ambulance services have a copay of $0-$295, while 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 Pennsylvania (PPO) plan. Emergency Services have a $110 copay, and Urgently Needed Services have a copay between $0 and $45; Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, while Worldwide Emergency Transportation has a $295 copay and 20% coinsurance.
Primary Care See details
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 are covered under the Devoted CHOICE Pennsylvania (PPO) plan. Chiropractic services have a $15 copay, while Occupational Therapy Services have a copay between $30 and $35. Physician Specialist Services have a $30 copay, and Mental Health Specialty Services, Psychiatric Services, and Opioid Treatment Program Services have a $30 copay for individual and group sessions. Physical Therapy and Speech-Language Pathology Services have a copay between $30 and $50, and Additional Telehealth Benefits have a copay between $0 and $30. 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, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, glaucoma screening, 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 due to chemotherapy, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers, 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 $25 copay, routine hearing exams (1 per year), and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a copay between $399 and $699 (2 per year), while inner ear, outer ear, and over the ear prescription hearing aids, as well as OTC hearing aids, are not covered.
Vision Services See details
The Devoted CHOICE Pennsylvania (PPO) plan covers vision services, including eye exams with a $25 copay. Eyewear is covered up to a combined maximum of $1000 per year for both in-network and out-of-network services, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The Devoted CHOICE Pennsylvania (PPO) plan covers dental services with a $1,000 annual maximum benefit. Medicare dental services require prior authorization and have a $30 copay, and other services like oral exams, dental x-rays, and orthodontics are covered.
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 20% coinsurance; for Medicare Part B Chemotherapy/Radiation Drugs, there is 0-20% coinsurance; and for Other Medicare Part B Drugs, there is 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE Pennsylvania (PPO) plan. You will pay 20% coinsurance for dialysis services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 0% to 18% coinsurance, Prosthetic Devices with 0% to 20% coinsurance, and Medical Supplies with 20% coinsurance. 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, diagnostic procedures/tests with a copay between $0 and $95, lab services with no copay, diagnostic radiological services with a copay up to $300, therapeutic radiological services with a 20% coinsurance, and outpatient X-ray services with no copay. Prior authorization is required for all diagnostic and radiological services.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE Pennsylvania (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Devoted CHOICE Pennsylvania (PPO) plan, but the specific services including Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. There is a copay for these services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Devoted CHOICE Pennsylvania (PPO) with prior authorization. For days 1-20 and 61-100, there is no copay, while days 21-60 have a $214 copay, and additional days beyond Medicare-covered are not covered.
Other Services See details
The "Other Services" benefit for Devoted CHOICE Pennsylvania (PPO) 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, or Self-Directed Personal Assistance Services. Other services include $0 preventive services with no maximum plan benefit coverage amount.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved