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DEVOTED CHOICE GIVEBACK 011 PA (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 011 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 011 PA (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 011 PA (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Western Pennsylvania 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 011 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 011 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 011 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 $148.10. 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 011 PA (PPO) prescription drug plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs are highly affordable with no copay for up to a three-month supply at standard pharmacies and standard mail order. Tier 2 generic drugs also offer low out-of-pocket costs, with standard copays starting at $3.00 for a one-month supply and capping at $9.00 for a three-month supply. For higher-tier medications, coverage transitions from flat copays to coinsurance. You will pay a 21% coinsurance for Tier 3 preferred brand drugs and a 25% coinsurance for Tier 4 non-preferred drugs. Tier 5 specialty drugs also require a 25% coinsurance for a one-month supply at standard pharmacies and standard mail order.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 011 PA (PPO) plan provides robust medical coverage with predictable out-of-pocket costs and no coinsurance for many key services. You will pay no copay for primary care doctor visits, preventive care, and home health services, while specialist visits require a $45 copay. Inpatient hospital stays require a $475 daily copay for the first four days and no copay for days five through ninety, while emergency room visits carry a $115 copay. For supplemental care, the plan features dental benefits up to a $250 annual limit and eyewear up to a $200 yearly limit with no copay. Routine hearing exams are available for a $45 copay, and skilled nursing facility stays require no copay for the first twenty days. These benefits are designed to keep your healthcare affordable and easy to manage throughout the year.
Inpatient Hospital See details
Inpatient hospital services are partially covered by DEVOTED CHOICE GIVEBACK 011 PA (PPO) with no coinsurance, requiring a $475 daily copay for days 1 through 4 and no copay for days 5 through 90. Non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 011 PA (PPO) covers outpatient services with no coinsurance, although prior authorization is required for most services. Outpatient hospital copays range from $0 to $575, observation services require a $475 copay per stay, and substance abuse sessions cost $45, while ambulatory surgical center and blood services are covered with no copays.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 011 PA (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to receive these services.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 011 PA (PPO) covers ambulance services with prior authorization, featuring a copay of $0 to $375 (and no coinsurance) for ground ambulance and a 20% coinsurance (and no copay) for air ambulance. Routine transportation services to health-related locations are not covered.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 011 PA (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services with no copay to a $40 copay and no coinsurance. Worldwide emergency coverage is limited to $25,000 and carries a $115 copay and no coinsurance for emergency or urgent care, and a $375 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 011 PA (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $45 copay and no coinsurance. Other covered benefits include physical therapy ($45 to $50 copay), occupational therapy ($35 copay), and mental health services ($45 copay) with no coinsurance, while podiatry is not covered and chiropractic services are only partially covered with routine care excluded.
Preventive Services See details
Preventive Services are partially covered by DEVOTED CHOICE GIVEBACK 011 PA (PPO) with no copay and no coinsurance for covered services such as annual physical exams, fitness benefits, and kidney disease education. However, this plan does not cover certain sub-services, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation sessions, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE GIVEBACK 011 PA (PPO), featuring routine hearing exams for a $45 copay and no coinsurance. Covered prescription hearing aids carry a $599 to $899 copay and no coinsurance, but OTC hearing aids and inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
DEVOTED CHOICE GIVEBACK 011 PA (PPO) partially covers vision services with no deductibles, providing one annual routine eye exam with a $0 to $20 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay or coinsurance up to a $200 annual maximum for contacts, lenses, frames, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE GIVEBACK 011 PA (PPO), with Medicare-covered dental requiring a $45 copay and no coinsurance, and other covered dental services having no copay and no coinsurance up to a $250 annual maximum. While many preventive and comprehensive services are covered, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 011 PA (PPO) covers Home Infusion bundled Services with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs have coinsurance ranging from no coinsurance to 20%, while Part B insulin has a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 011 PA (PPO) covers dialysis services with no copay and 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 011 PA (PPO) partially covers medical equipment with no copays, featuring 19% to 20% coinsurance for durable medical equipment (DME) and no coinsurance to 20% coinsurance for prosthetics, medical supplies, and diabetic supplies. Prior authorization is required for these services, and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 011 PA (PPO) covers diagnostic and radiological services with prior authorization, offering diagnostic services with no coinsurance, no copay for lab services, and a $0 to $95 copay for diagnostic procedures. Radiological services feature outpatient X-rays and diagnostic radiological services starting at no copay, while therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home health services are covered under the DEVOTED CHOICE GIVEBACK 011 PA (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE GIVEBACK 011 PA (PPO) covers some cardiac rehabilitation services with no coinsurance and required prior authorization, although standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by DEVOTED CHOICE GIVEBACK 011 PA (PPO) with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 011 PA (PPO) partially covers Other Services, offering additional preventive services not covered by Medicare with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered under this plan.
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