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DEVOTED CHOICE MA ONLY 003 SC (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE MA ONLY 003 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 MA ONLY 003 SC (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE MA ONLY 003 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 MA ONLY 003 SC (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 CHOICE MA ONLY 003 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 MA ONLY 003 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.
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 $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
Prescription drugs are not covered by DEVOTED CHOICE MA ONLY 003 SC (PPO).
Additional Benefits
The DEVOTED CHOICE MA ONLY 003 SC (PPO) plan offers comprehensive medical coverage, including primary care visits, annual physicals, and home health services with no copay. For inpatient hospital stays, members pay a daily copay of $425 for days one through four and no copay for days five through ninety. Specialist visits require a $50 copay, while emergency room services carry a $115 copay that is waived upon hospital admission. Additional perks include preventive dental care and routine eye exams with no copay, alongside a $400 annual allowance for eyewear. Members also benefit from diagnostic lab services, outpatient X-rays, and up to $50 every three months for over-the-counter items with no copay. Hearing exams are covered with a $50 copay, and the plan offers coverage for up to two prescription hearing aids per year.
Inpatient Hospital See details
DEVOTED CHOICE MA ONLY 003 SC (PPO) covers inpatient acute and psychiatric hospital services with no coinsurance, requiring a $425 daily copay for days 1 through 4 and no copay for days 5 through 90. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE MA ONLY 003 SC (PPO) covers outpatient services with no coinsurance, 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 are offered with no copay and no coinsurance, while outpatient substance abuse sessions have a $50 copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by DEVOTED CHOICE MA ONLY 003 SC (PPO) with a $70.00 copay and no coinsurance. Prior authorization is required to access these benefits.
Ambulance and Transportation Services See details
DEVOTED CHOICE MA ONLY 003 SC (PPO) covers ground ambulance services with coinsurance and a copay ranging from no copay to $350, and air ambulance services with a 20% coinsurance and a copay, both requiring prior authorization. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
DEVOTED CHOICE MA ONLY 003 SC (PPO) covers emergency services with a $115 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 $40 copay with no coinsurance, while worldwide emergency services are covered up to $25,000 with a $115 copay for emergency and urgent care, and a $350 copay and 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE MA ONLY 003 SC (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $50 copay and no coinsurance. Occupational therapy features a $35 copay and no coinsurance, telehealth services range from a $0 to $50 copay with no coinsurance, and chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are covered by DEVOTED CHOICE MA ONLY 003 SC (PPO) with no copay and no coinsurance for annual physical exams, fitness benefits, and kidney disease education. This benefit is partially covered, as specific services such as in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, and counseling are not covered.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE MA ONLY 003 SC (PPO), offering hearing exams for a $50 copay and no coinsurance, and up to two prescription hearing aids per year for a $599 to $899 copay and no coinsurance. OTC hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE MA ONLY 003 SC (PPO), which excludes other eye exam services. Covered benefits include one annual routine eye exam with a $0 to $50 copay and no coinsurance, plus up to $400 yearly for eyewear with no copay, no coinsurance, and no deductible.
Dental Services See details
Dental Services under DEVOTED CHOICE MA ONLY 003 SC (PPO) are partially covered up to a $1,000 annual maximum for both in- and out-of-network care, with no copay and no coinsurance for preventive services. Comprehensive dental services feature no copay and 0% to 50% coinsurance, while Medicare-covered dental requires a $50 copay and no coinsurance; however, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED CHOICE MA ONLY 003 SC (PPO) with no copay, while associated Medicare Part B chemotherapy, radiation, and other drugs require no coinsurance to 20% coinsurance. Covered Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance, with prior authorization and step therapy applying to certain services.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CHOICE MA ONLY 003 SC (PPO) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
DEVOTED CHOICE MA ONLY 003 SC (PPO) partially covers medical equipment with no copays, though prior authorization is required. Durable medical equipment carries a 20% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance to 20% coinsurance, with the exception of diabetic therapeutic shoes and inserts which are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CHOICE MA ONLY 003 SC (PPO) with prior authorization required. Lab services and outpatient X-rays feature no copay, diagnostic procedures and tests have no coinsurance and a copay of $0 to $95, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
DEVOTED CHOICE MA ONLY 003 SC (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE MA ONLY 003 SC (PPO) partially covers Cardiac Rehabilitation Services with no coinsurance, though standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by DEVOTED CHOICE MA ONLY 003 SC (PPO) with no coinsurance, offering no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, a prior three-day hospital stay is not needed, and additional days beyond the standard 100-day Medicare benefit are not covered.
Other Services See details
DEVOTED CHOICE MA ONLY 003 SC (PPO) offers partial coverage for other services, featuring no copay and no coinsurance for additional preventive services and over-the-counter items up to $50 every three months. Acupuncture, meal benefits, and other supplemental services are not covered.
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