A non-government entity
Devoted CHOICE GIVEBACK Indiana (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE GIVEBACK Indiana (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 Indiana (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE GIVEBACK Indiana (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 2025.
It's important to know that Devoted CHOICE GIVEBACK Indiana (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 Indiana (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 Indiana (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 $167.70. 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 $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:
Sign up for Devoted CHOICE GIVEBACK Indiana (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Devoted CHOICE GIVEBACK Indiana (PPO) plan has a $590 deductible for prescription drugs. After you meet the deductible, you'll pay a copay or coinsurance for your medications depending on the drug tier and the pharmacy you use. For preferred generic drugs at a standard pharmacy or through mail order, the copay is $5.00. For standard generic, preferred brand, and non-preferred drugs, you will pay 25% coinsurance at a standard pharmacy or through mail order. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Devoted CHOICE GIVEBACK Indiana (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $300 copay for the first five days, with no copay for the following days, while outpatient services have copays ranging from $0 to $400. You'll also find coverage for primary care, hearing, vision, and dental services, with copays and coinsurance applying depending on the specific service. This plan also includes coverage for emergency services, ambulance services, and home health services with no copay. Additionally, it covers home infusion services, dialysis, and medical equipment. However, it's important to note that certain services like acupuncture, over-the-counter items, and specific rehabilitation and home health services are not covered.
Inpatient Hospital See details
Inpatient hospital services are covered, including acute and psychiatric care, with a copay of $300 for days 1-5 and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered, but 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 also not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $400, observation services have a $400 copay, and ambulatory surgical center services have no copay. Individual and group sessions for outpatient substance abuse have a copay of $45, and outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan. The plan has a $70 copay for this benefit, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan, with prior authorization required for all ambulance services. Ground ambulance services have a copay of $0-$350, while air ambulance services have a 20% coinsurance; however, 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 by the Devoted CHOICE GIVEBACK Indiana (PPO) plan. Emergency Services have a $110 copay, and Urgently Needed Services have a copay between $0 and $45. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, and Worldwide Emergency Transportation has a $350 copay and 20% coinsurance.
Primary Care See details
The Devoted CHOICE GIVEBACK Indiana (PPO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, physician specialist services with a $45 copay, mental health specialty services with a $45 copay, other health care professional services with a $0-$45 copay, psychiatric services with a $45 copay, physical therapy and speech-language pathology services with a $45-$50 copay, additional telehealth benefits with a $0-$45 copay, and opioid treatment program services with a $45 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Devoted CHOICE GIVEBACK Indiana (PPO) plan covers preventive services, including health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. However, the plan does not cover 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, or counseling services.
Hearing Services See details
Hearing Services includes hearing exams with a $45 copay, along with routine hearing exams and fitting/evaluation for hearing aids. Prescription hearing aids are covered with a copay between $599 and $899, but prescription hearing aids for the inner, outer, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $20 copay. Eyewear benefits include a combined maximum of $250.00 every year for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, all of which are covered.
Dental Services See details
Dental services are covered, with a $45 copay for Medicare Dental Services. Other dental services have a maximum benefit of $250 per year, covering 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. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered. For Medicare Part B Insulin Drugs, there is a $35 copay, with coinsurance between 20% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment coverage includes Durable Medical Equipment (DME) with 15% coinsurance and no copay, Prosthetics/Medical Supplies with coinsurance for Medicare-covered devices and supplies, and Diabetic Equipment. Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, with a copay between $0 and $95 for diagnostic procedures and tests, and no copay for lab services. Therapeutic Radiological Services have a coinsurance of at most 20%, while Diagnostic Radiological Services have a copay of at most $300, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK Indiana (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 technically covered, but the plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. There is a copay for some services, but the specific amount is not detailed.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan, with a $0 copay for days 1-20 and days 61-100, and a $214 copay for days 21-60. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services offered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan are not covered, including 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, and Self-Directed Personal Assistance Services. However, $0 preventive services are covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved