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DEVOTED CHOICE GIVEBACK 002 IN (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 002 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 GIVEBACK 002 IN (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 002 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 GIVEBACK 002 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 GIVEBACK 002 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 GIVEBACK 002 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. Additionally, this plan comes with a Part B Premium reduction of $183.00. 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.
This plan has a $605.00 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 $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
The DEVOTED CHOICE GIVEBACK 002 IN (PPO) plan features an annual drug deductible of $605. Under this plan, you will have no copay for Tier 1 preferred generic drugs through standard pharmacies and standard mail order services. For Tier 2 generic drugs, standard pharmacy copays range from $3 for a one-month supply to $9 for a three-month supply, with mail order offering a slightly discounted $7.50 copay for a three-month fill. For brand-name and specialty medications, costs are based on coinsurance rather than flat copays. You will pay 21% coinsurance for Tier 3 preferred brand drugs and 25% coinsurance for Tier 4 non-preferred drugs. Tier 5 specialty drugs also require a 25% coinsurance and are limited to a one-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 002 IN (PPO) plan features no copay for primary care visits, while specialist visits require a $45 copay and no coinsurance. For hospital care, inpatient acute stays require a $425 daily copay for days 1 through 5 with no copay thereafter, whereas outpatient hospital services range from no copay up to a $525 copay. Emergency room visits carry a $115 copay, which is waived if you are admitted to the hospital within 24 hours. Preventive care, home health services, and most dental care are available with no copay and no coinsurance, though dental benefits have an annual maximum of $250. Routine vision and hearing exams require low copays, with up to $200 covered annually for eyewear and prescription hearing aids requiring a copay of $599 to $899. Durable medical equipment requires an 18% coinsurance, and dialysis services require a 20% coinsurance with no copay.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 002 IN (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, though prior authorization is required. Acute stays require a $425 daily copay for days 1 through 5 and no copay for days 6 through 90, while psychiatric stays require a $425 daily copay for days 1 through 4 and no copay for days 5 through 90. Non-Medicare-covered stays, room upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 002 IN (PPO) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services have a $0 to $525 copay, observation services have a $425 copay per stay, and outpatient substance abuse sessions carry a $45 copay, with prior authorization required for most benefits.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 002 IN (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 002 IN (PPO) covers ground ambulance services with a copay of $0 to $350 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, both requiring prior authorization. Transportation services, including trips to plan-approved or any health-related locations, are not covered under this plan.
Emergency Services See details
Emergency services are covered by DEVOTED CHOICE GIVEBACK 002 IN (PPO) with a $115 copay and no coinsurance, with the copay waived if admitted to the hospital within 24 hours. Urgently needed services range from no copay to a $40 copay with no coinsurance, and worldwide emergency services are covered up to $25,000 with a $115 copay and no coinsurance for care, and a $350 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
Primary care benefits under DEVOTED CHOICE GIVEBACK 002 IN (PPO) are partially covered because podiatry is not covered, and while some chiropractic services are covered, routine and other chiropractic services are not covered. Covered services feature no coinsurance, with no copay for primary care visits, a $45 copay for specialists, and copays ranging from $35 to $50 for physical, occupational, and mental health therapies.
Preventive Services See details
Preventive services under DEVOTED CHOICE GIVEBACK 002 IN (PPO) are covered with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management. Additional preventive benefits are partially covered with no copay and no coinsurance, offering fitness and weight management programs but excluding services like therapeutic massage, in-home support, and personal emergency response systems.
Hearing Services See details
DEVOTED CHOICE GIVEBACK 002 IN (PPO) provides partially covered hearing services with no deductible, including routine hearing exams for a $45 copay and no coinsurance. Prescription hearing aids are covered with no coinsurance and a copay of $599 to $899, but OTC hearing aids and inner-ear, outer-ear, or over-the-ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE GIVEBACK 002 IN (PPO), offering one routine eye exam per year with a copay of $0 to $45 and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay or coinsurance up to a combined annual maximum of $200 for contacts, lenses, frames, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE GIVEBACK 002 IN (PPO), offering no copay and no coinsurance for most preventive and comprehensive care up to an annual maximum of $250 for both in-network and out-of-network services. Medicare-covered dental services require a $45 copay and no coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by DEVOTED CHOICE GIVEBACK 002 IN (PPO) with no copay, although prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and radiation, require up to 20% coinsurance, while Part B insulin is covered with a $35 copay and up to 20% coinsurance.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 002 IN (PPO) covers dialysis services with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 002 IN (PPO) partially covers medical equipment with no copay, though prior authorization is required. Durable medical equipment carries an 18% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance up to 20% coinsurance, but diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 002 IN (PPO) covers diagnostic and radiological services with prior authorization required. Lab services and outpatient X-rays have no copay, diagnostic procedures and tests feature a copay of $0 to $95 with no coinsurance, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home health services are covered by the DEVOTED CHOICE GIVEBACK 002 IN (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE GIVEBACK 002 IN (PPO) covers Cardiac Rehabilitation Services with no coinsurance, although prior authorization is required. While some services are covered, cardiac rehabilitation (with a $30.00 copay), intensive cardiac rehabilitation (with a $30.00 copay), pulmonary rehabilitation (with a $25.00 copay), and supervised exercise therapy for symptomatic peripheral artery disease (with a $20.00 copay) are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 002 IN (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 002 IN (PPO) partially covers other services, offering additional preventive services not covered by Medicare with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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