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Devoted CHOICE GIVEBACK South Carolina (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE GIVEBACK South Carolina (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 South Carolina (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE GIVEBACK South Carolina (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 2025.
It's important to know that Devoted CHOICE GIVEBACK South Carolina (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 South Carolina (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 South Carolina (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 $157.70. 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 South Carolina (PPO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590.00. If you qualify for the low-income subsidy, you will have no copay for Part D drugs. After meeting the deductible, you will pay a $2.00 copay for preferred generic drugs at standard and mail order pharmacies. For standard generic, preferred brand, and non-preferred drugs, you will pay 25% coinsurance. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase.
Additional Benefits
The Devoted CHOICE GIVEBACK South Carolina (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient hospital services, with varying copays depending on the service. The plan covers primary care, specialist visits, and mental health services, each with a copay, as well as preventive services with no copay. Additional benefits include hearing and vision services, with copays for exams and allowances for eyewear and hearing aids. Dental services are covered with a copay for Medicare dental services, and there is an annual maximum for other dental services. The plan also covers ambulance services, home infusion, and medical equipment, with varying copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, both of which require prior authorization. For Inpatient Hospital-Acute, you will pay a $425 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you will pay a $425 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered, while non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered by Devoted CHOICE GIVEBACK South Carolina (PPO). Outpatient Hospital Services have a copay between $0 and $525, Observation Services have a $425 copay, and Ambulatory Surgical Center (ASC) Services have no copay. Individual and Group Sessions for Outpatient Substance Abuse have a copay of $45. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE GIVEBACK South Carolina (PPO) plan, with a $60 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE GIVEBACK South Carolina (PPO) plan. Ground ambulance services have a copay between $0 and $300, 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. Emergency Services have a $125 copay, Urgently Needed Services have a copay between $0 and $55, and Worldwide Emergency Transportation has a $300 copay and 20% coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 copay.
Primary Care See details
Devoted CHOICE GIVEBACK South Carolina (PPO) covers primary care services, chiropractic services with a $20 copay, occupational therapy with a $45 copay, physician specialist services with a $45 copay, and physical therapy and speech-language pathology services with a $45-$50 copay. The plan also covers mental health and psychiatric services with a $45 copay, other health care professionals with a $0-$45 copay, and opioid treatment program services with a $45 copay, and additional telehealth benefits with a $0-$45 copay. Routine chiropractic care is not covered, and podiatry services are not covered.
Preventive Services See details
The Devoted CHOICE GIVEBACK South Carolina (PPO) plan covers preventive services, including an annual physical exam, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit. However, in-home safety assessment, personal emergency response system, medical nutrition therapy, post discharge in-home medication reconciliation, re-admission 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, and counseling services are not covered.
Hearing Services See details
Hearing services include hearing exams with a $45 copay, and prescription hearing aids with a copay between $599 and $899 depending on the type of aid. This plan does not cover prescription hearing aids for the inner, outer, and over the ear, and does not cover OTC hearing aids.
Vision Services See details
Vision services include eye exams with a $45 copay, and eyewear with a combined maximum benefit of $500 every 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 are covered by Devoted CHOICE GIVEBACK South Carolina (PPO), with a $45 copay for Medicare Dental Services, and a $500 annual maximum for Other Dental Services. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Insulin, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. Medicare Part B Insulin Drugs have a $35 copay and 20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE GIVEBACK South Carolina (PPO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetics/Medical Supplies with a 0-20% coinsurance, while Diabetic Equipment is covered, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered. Durable Medical Equipment for use outside the home is also not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by this plan, with prior authorization required. Diagnostic Procedures/Tests have a copay between $0 and $95, and Lab Services have no copay. Diagnostic Radiological Services have a copay of up to $300, while Therapeutic Radiological Services have a coinsurance of at least 20%. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK South Carolina (PPO) plan with no copay or coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted CHOICE GIVEBACK South Carolina (PPO) plan. Specifically, Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE GIVEBACK South Carolina (PPO) plan, with prior authorization required. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services are not covered, including acupuncture, over-the-counter items, meal benefits, Dual Eligible SNPs, 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. However, $0 preventive services are covered.
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