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Devoted LIBERTY CHOICE South Carolina (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted LIBERTY CHOICE 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 LIBERTY CHOICE South Carolina (PPO) in 2025, please refer to our full plan details page.
Devoted LIBERTY CHOICE 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 LIBERTY CHOICE South Carolina (PPO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Devoted LIBERTY CHOICE 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 LIBERTY CHOICE 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 $160.00. 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.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $14000.00 (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 $14000.00 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
Prescription drugs are not covered by Devoted LIBERTY CHOICE South Carolina (PPO).
Additional Benefits
The Devoted LIBERTY CHOICE South Carolina (PPO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services, and emergency services with varying copays and coinsurance. The plan covers primary care, preventive services, hearing exams, and vision services with copays, and dental services with a maximum benefit of $250 per year. Additionally, the plan provides coverage for home infusion, dialysis, medical equipment, and diagnostic services with copays or coinsurance. This plan also includes coverage for skilled nursing facilities with a copay, and home health services with no copay. However, this plan does not cover cardiac rehabilitation, additional hours of care, and some other services like acupuncture, over-the-counter items, and certain types of dental and vision services.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with a $425 copay for days 1-4, and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services with a copay of $0-$525, observation services with a $425 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with a copay of $45 for individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by Devoted LIBERTY CHOICE South Carolina (PPO) with a $70 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a copay between $0 and $350, 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 has a $110 copay, Urgently Needed Services has a copay of $0-$45, and Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, while Worldwide Emergency Transportation has a $350 copay and 20% coinsurance.
Primary Care See details
Primary Care Physician 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. Chiropractic Services are partially covered, but routine chiropractic care is not covered, and Podiatry Services are not covered. Other services have a copay, including a $35 copay for Occupational Therapy Services, a $50 copay for Physician Specialist Services, a $45 copay for individual and group mental health and psychiatric sessions, a $0-$50 copay for Additional Telehealth Benefits, and a $50 copay for Physical Therapy and Speech-Language Pathology Services; all other services have no coinsurance.
Preventive Services See details
The Devoted LIBERTY CHOICE South Carolina (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, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following 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 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 include hearing exams with a $50 copay, and prescription hearing aids with a copay between $599 and $899 per year for all types, but do not cover prescription hearing aids for the inner ear, outer ear, and over the ear. Routine hearing exams are covered for one visit per year, and fitting/evaluation for hearing aids is unlimited.
Vision Services See details
Vision services include routine eye exams with a $20 copay, and eyewear including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, with a combined maximum of $250 per year.
Dental Services See details
Dental services include coverage for Medicare dental services with a $50 copay, oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. Other dental services have a maximum plan benefit of $250 per year. Maxillofacial prosthetics, implant services, and orthodontics are not 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 a 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 LIBERTY CHOICE South Carolina (PPO) plan. There is a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 18-20% coinsurance, and Prosthetics/Medical Supplies with 20% coinsurance for Medicare-covered supplies, but Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. Prosthetic Devices have a coinsurance between 0-20%.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services with a copay, diagnostic procedures/tests with a copay between $0 and $95, lab services with no copay, diagnostic radiological services with a copay at most $300, therapeutic radiological services with coinsurance at least 20%, and outpatient X-ray services with no copay. Radiological services require coinsurance for Medicare-covered X-Ray services.
Home Health Services See details
Home Health Services are covered by the Devoted LIBERTY CHOICE South Carolina (PPO) plan with no copay and no 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 LIBERTY CHOICE South Carolina (PPO) plan. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted LIBERTY CHOICE South Carolina (PPO) plan. For days 1-20 and 61-100, there is no copay, but for days 21-60, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Devoted LIBERTY CHOICE South Carolina (PPO) plan does not cover 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, or self-directed personal assistance services. Other Services and Other 2 benefits are covered, and there is no copay for preventive services.
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