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DEVOTED CHOICE GIVEBACK 002 SC (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 002 SC (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 002 SC (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 002 SC (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in South Carolina. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 002 SC (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 002 SC (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 002 SC (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 $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 002 SC (PPO) Medicare prescription drug plan features an annual drug deductible of $605. For Tier 1 preferred generic drugs, members pay no copay for standard retail pharmacy and standard mail-order fills. Tier 2 generic drugs are highly affordable, starting at a $3.00 copay for a one-month supply at standard pharmacies and standard mail order. Higher-tier medications are subject to coinsurance rather than flat copayments. Tier 3 preferred brand drugs require a 22% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs carry a 25% coinsurance. These coinsurance rates apply to both standard pharmacy and standard mail-order services across one-month, two-month, and three-month supplies where applicable.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 002 SC (PPO) plan offers comprehensive medical coverage with predictable out-of-pocket costs and no copay for primary care visits. For specialist visits, you will pay a copay ranging from no copay to $50, while inpatient hospital stays require a $425 daily copay for days one through five and no copay for days six through 90. Emergency room visits carry a $130 copay, which is waived if you are admitted to the hospital within 24 hours. In addition to core medical care, this plan provides valuable preventive, dental, and vision benefits with no copay or coinsurance. Members receive a $200 annual limit for eyewear and up to $500 in dental services with no copay, alongside home health services covered at no copay. While medical equipment requires no copay, durable medical equipment is subject to a 20% to 50% coinsurance.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 002 SC (PPO) covers inpatient hospital services with no coinsurance, requiring a $425 daily copay for days 1 through 5 and no copay for days 6 through 90. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED CHOICE GIVEBACK 002 SC (PPO) with no coinsurance for all services, featuring a copay of $0 to $525 for outpatient hospital services and $425 per stay for observation services. Ambulatory surgical center and outpatient blood services have no copay and no coinsurance, while outpatient substance abuse sessions require a $45 copay with no coinsurance.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 002 SC (PPO) covers partial hospitalization services with a $60.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by DEVOTED CHOICE GIVEBACK 002 SC (PPO), as transportation services are not covered. Prior authorized ground ambulance services require a copay ranging from no copay to $315 with no coinsurance, while air ambulance services require a 20% coinsurance with no copay.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 002 SC (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services range from no copay to a $45 copay with no coinsurance, while worldwide emergency services are covered up to $25,000 with a $130 copay and no coinsurance for emergency/urgent care, and a $315 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 002 SC (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits, therapy, and mental health services require copays ranging from $0 to $50 and no coinsurance. Chiropractic and podiatry services are not covered under this plan.
Preventive Services See details
DEVOTED CHOICE GIVEBACK 002 SC (PPO) offers partially covered preventive services with no copay and no coinsurance for covered benefits such as annual physical exams and kidney disease education. However, the plan does not cover in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs for chemotherapy-related hair loss, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional tobacco cessation counseling, enhanced disease management, telemonitoring, remote access technologies, and counseling services.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE GIVEBACK 002 SC (PPO), featuring routine hearing exams for a $45 copay and no coinsurance. The plan also covers up to two prescription hearing aids per year with copays ranging from $599 to $899 and no coinsurance, though OTC hearing aids and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
DEVOTED CHOICE GIVEBACK 002 SC (PPO) provides partially covered vision services, including one annual routine eye exam with a $0 to $45 copay, no coinsurance, and no deductible, though other eye exam services are not covered. Eyewear is fully covered with no copay, no coinsurance, and no deductible, offering a $200 annual maximum benefit for contacts, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE GIVEBACK 002 SC (PPO), offering Medicare-covered dental care for a $45 copay and no coinsurance, alongside other dental services with no copay and no coinsurance up to a $500 annual limit. While preventive, diagnostic, and restorative treatments are covered, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 002 SC (PPO) covers Home Infusion bundled Services with no copay and no coinsurance, subject to prior authorization. Under this plan, Medicare Part B chemotherapy, radiation, and other Part B drugs carry no copay and a 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 002 SC (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 002 SC (PPO) covers medical equipment with no copays, although prior authorization is required. Durable medical equipment has a 20% to 50% coinsurance, prosthetics and medical supplies range from no coinsurance to 20% coinsurance, and diabetic equipment is partially covered with no coinsurance to 50% coinsurance for supplies, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CHOICE GIVEBACK 002 SC (PPO), with prior authorization required for both. Diagnostic services feature no coinsurance, offering no copay for lab services and a $0 to $95 copay for diagnostic procedures, while radiological services include no-copay outpatient X-rays and diagnostic radiology alongside therapeutic radiology with a 20% minimum coinsurance.
Home Health Services See details
DEVOTED CHOICE GIVEBACK 002 SC (PPO) covers Home Health Services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED CHOICE GIVEBACK 002 SC (PPO) with no coinsurance and require prior authorization, though in practice only some services are covered. Standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and carry copayments ranging from $25 to $40.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 002 SC (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 002 SC (PPO) partially covers other services, with acupuncture, meal benefits, and certain other options not covered. Covered benefits include over-the-counter (OTC) items up to $30 every three months and additional preventive services, both of which are available with no copay and no coinsurance.
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