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Devoted CHOICE GIVEBACK Arizona (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE GIVEBACK Arizona (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 Arizona (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE GIVEBACK Arizona (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Rural Arizona. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Devoted CHOICE GIVEBACK Arizona (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 Arizona (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 Arizona (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 $122.70. 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 $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 GIVEBACK Arizona (PPO) plan has a $590 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For drugs in the initial coverage phase, you may pay a $10 copay for preferred generic drugs at standard and mail order pharmacies. For other tiers, you may pay 25% coinsurance. After your yearly out-of-pocket drug costs reach $2000, you will enter the catastrophic coverage phase where you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Devoted CHOICE GIVEBACK Arizona (PPO) plan offers a range of benefits including inpatient and outpatient hospital care, with varying copays. The plan covers primary care with no copay, along with hearing and vision services, including eyewear and hearing aids. Dental services are included, with a $250 annual maximum. This plan provides coverage for emergency and ambulance services, with both copays and coinsurance. It also includes home health services with no copay, but excludes some services like cardiac rehabilitation, acupuncture, and certain other services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization; Inpatient Hospital-Acute has a $475 copay for days 1-4 and no copay for days 5-90, while Inpatient Hospital Psychiatric has a $475 copay for days 1-3 and no copay for days 4-90. 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 are covered by the Devoted CHOICE GIVEBACK Arizona (PPO) plan, including Outpatient Hospital Services with a copay ranging from $0 to $575, Observation Services with a $475 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a $45 copay for both individual and group sessions, and Outpatient Blood Services.
Partial Hospitalization See details
Partial Hospitalization is covered under the Devoted CHOICE GIVEBACK Arizona (PPO) plan, with a $70 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE GIVEBACK Arizona (PPO) plan. Ground ambulance services have a copay between $0 and $395, while air ambulance services have a 20% coinsurance. 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 GIVEBACK Arizona (PPO) plan. Emergency Services has a $110 copay, and Urgently Needed Services has a copay between $0 and $45; Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, while Worldwide Emergency Transportation has a $395 copay and 20% coinsurance.
Primary Care See details
The Devoted CHOICE GIVEBACK Arizona (PPO) plan covers primary care services, including primary care physician services, with no copay. Chiropractic services have a $15 copay. Occupational Therapy Services have a $35 copay, while Physician Specialist Services have a $45 copay. Individual and Group Sessions for Mental Health and Psychiatric Specialty Services, and Opioid Treatment Program Services, each have a $45 copay. Physical Therapy and Speech-Language Pathology Services have a copay between $45 and $50. Additional Telehealth Benefits have a copay between $0 and $45. Podiatry Services are not covered.
Preventive Services See details
The Devoted CHOICE GIVEBACK Arizona (PPO) plan covers a variety of preventive services, including 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. 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, and counseling services are not covered.
Hearing Services See details
Hearing services are covered, including routine hearing exams with a $45 copay, fitting/evaluation for hearing aids, and prescription hearing aids. Prescription hearing aids (all types) have a copay between $599 and $899, but inner ear, outer ear, and over-the-ear prescription hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a $45 copay. The plan also covers eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, with a combined maximum benefit of $250 every year for all eyewear.
Dental Services See details
The Devoted CHOICE GIVEBACK Arizona (PPO) plan covers Medicare Dental Services with a $45 copay, and other dental services, including oral exams, dental x-rays, and other diagnostic services, with a $250 annual maximum. The plan does not cover Maxillofacial Prosthetics, Implant Services, and Orthodontics.
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 by the Devoted CHOICE GIVEBACK Arizona (PPO) plan. The coinsurance for Dialysis Services is between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits are covered by the Devoted CHOICE GIVEBACK Arizona (PPO) plan, including Durable Medical Equipment (DME) with a 19% coinsurance and no copay, Prosthetic Devices with 0-20% coinsurance and no copay, and Medical Supplies with a 20% coinsurance and no copay; however, 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 are covered, including Diagnostic Procedures/Tests with a copay between $0 and $95, Lab Services with no copay, and Outpatient X-Ray Services with no copay. Diagnostic Radiological Services have a maximum copay of $300, while Therapeutic Radiological Services have a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK Arizona (PPO) plan with no copay and no coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted CHOICE GIVEBACK Arizona (PPO) plan. Although the plan covers Cardiac Rehabilitation Services, it 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 by the Devoted CHOICE GIVEBACK Arizona (PPO) plan with prior authorization required. You will have no copay for days 1-20, a $214 copay for days 21-60, and no copay for days 61-100.
Other Services See details
Other Services are not covered, including acupuncture, over-the-counter 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. Some other services are covered, including $0 preventive services, with no copay.
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