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DEVOTED CHOICE 001 IN (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE 001 IN (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED CHOICE 001 IN (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE 001 IN (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Northeast Indiana. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE 001 IN (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 001 IN (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 001 IN (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.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $10100.00 (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 $10100.00 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 001 IN (PPO) Medicare plan features a $0 drug deductible, meaning your prescription drug coverage begins immediately with no upfront deductible costs. For Tier 1 preferred generic and Tier 2 generic drugs, you will pay no copay for one-month, two-month, or three-month supplies filled at standard pharmacies or through standard mail order. This makes managing your essential, everyday medications highly affordable under this plan. For brand-name and specialty medications, the plan transitions to a coinsurance-based cost-sharing structure. You will pay a 19% coinsurance for Tier 3 preferred brand drugs and a 25% coinsurance for Tier 4 non-preferred drugs at standard pharmacies and through standard mail order. Additionally, Tier 5 specialty drugs require a 31% coinsurance for a one-month supply.
Additional Benefits
The DEVOTED CHOICE 001 IN (PPO) plan provides comprehensive medical coverage, including primary care visits and home health services with no copay and no coinsurance. For inpatient hospital stays, members pay a $295 daily copay for days 1 through 7, followed by no copay for days 8 through 90. Emergency room visits carry a $130 copay, which is waived if you are admitted to the hospital within 24 hours. This plan also features valuable supplemental benefits, such as dental care up to a $2,000 annual limit with no copay for preventive services, and routine eye exams alongside a $300 annual eyewear allowance. Routine hearing exams require a $35 copay, and skilled nursing facility care is available with no copay for the first 20 days. Durable medical equipment and dialysis services are covered with no copay and a 20% coinsurance.
Inpatient Hospital See details
DEVOTED CHOICE 001 IN (PPO) covers inpatient acute and psychiatric hospital stays with prior authorization and no coinsurance, requiring a $295 daily copay for days 1 through 7 and no copay for days 8 through 90. This benefit is partially covered as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, though unlimited additional acute hospital days are covered.
Outpatient Services See details
DEVOTED CHOICE 001 IN (PPO) offers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital services require a copay of $0 to $395, observation services have a $295 copay per stay, and outpatient substance abuse sessions have a $35 copay, with prior authorization required for these benefits.
Partial Hospitalization See details
DEVOTED CHOICE 001 IN (PPO) covers partial hospitalization services with a $60.00 copay and no coinsurance. Prior authorization is required to access this covered benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE 001 IN (PPO) covers ambulance services with prior authorization, featuring a copay ranging from no copay to $315 (and no coinsurance) for ground transport, and a 20% coinsurance (and no copay) for air transport. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Emergency services are covered by DEVOTED CHOICE 001 IN (PPO) 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. Worldwide emergency coverage is limited to $25,000 and features a $130 copay with no coinsurance for emergency and urgent care, and a $315 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE 001 IN (PPO) offers primary care physician services with no copay and no coinsurance, alongside telehealth benefits with a $0 to $45 copay and no coinsurance. Specialist, therapy, and mental health services are covered with copays ranging from $35 to $50 and no coinsurance, while chiropractic services are partially covered and podiatry is not covered.
Preventive Services See details
Preventive services are partially covered by DEVOTED CHOICE 001 IN (PPO) with no copay and no coinsurance for covered benefits like annual physicals and fitness programs. However, the plan does not cover several sub-services, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, and counseling.
Hearing Services See details
DEVOTED CHOICE 001 IN (PPO) hearing services include one routine hearing exam per year for a $35 copay and no coinsurance, with no deductible. Up to two prescription hearing aids are covered annually with no coinsurance and a copay ranging from $399 to $699, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
DEVOTED CHOICE 001 IN (PPO) vision services are partially covered, as other eye exam services are not covered. Routine eye exams are covered with a $0 to $35 copay and no coinsurance, while eyewear is covered with no copay or coinsurance up to a combined annual maximum of $300.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE 001 IN (PPO) up to a $2,000 annual limit, featuring no copay and no coinsurance for preventive care, and no copay with 0% to 50% coinsurance for restorative and endodontic treatments. Medicare-covered dental services require a $35 copay and no coinsurance, while orthodontics, implant services, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE 001 IN (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Associated Medicare Part B chemotherapy, radiation, and other drugs have no copay and up to 20% coinsurance, while covered Part B insulin has a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
DEVOTED CHOICE 001 IN (PPO) covers dialysis services with no copay and a 20% coinsurance, and prior authorization is required.
Medical Equipment See details
DEVOTED CHOICE 001 IN (PPO) covers medical equipment with no copays, featuring a 20% coinsurance for durable medical equipment and no coinsurance to 20% coinsurance for prosthetics and medical supplies. Diabetic equipment is partially covered with no copay and no coinsurance to 20% coinsurance for diabetic supplies, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE 001 IN (PPO) covers diagnostic and radiological services with prior authorization required, offering lab services and outpatient X-rays for no copay, though X-rays are subject to coinsurance. Diagnostic procedures and tests feature no coinsurance with copays ranging from $0 to $95, while therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED CHOICE 001 IN (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under DEVOTED CHOICE 001 IN (PPO), as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by DEVOTED CHOICE 001 IN (PPO) with no coinsurance, offering no copay for the first 20 days and a $218 daily copay for days 21 through 100. Prior authorization is required, though a prior three-day hospital stay is not necessary for admission.
Other Services See details
Other services are partially covered by DEVOTED CHOICE 001 IN (PPO), including over-the-counter (OTC) items and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and other additional services are not covered under this plan.
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