A non-government entity
DEVOTED CHOICE 005 IN (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE 005 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 005 IN (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE 005 IN (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Northwest/North Central Indiana. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE 005 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 005 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 005 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 $9550.00 (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 $9550.00 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 005 IN (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 005 IN (PPO) Medicare plan features a $0 drug deductible, meaning your prescription drug coverage begins immediately without any out-of-pocket deductible costs. Under this plan, there is no copay for Tier 1 (Preferred Generic) and Tier 2 (Generic) medications filled at standard pharmacies or through standard mail order. This ensures that essential everyday prescriptions remain highly affordable for members. For brand-name and specialty medications, costs are structured around coinsurance. You will pay a 19% coinsurance for Tier 3 (Preferred Brand) drugs and a 25% coinsurance for Tier 4 (Non-Preferred) drugs. Tier 5 (Specialty Tier) medications carry a 31% coinsurance for a one-month supply at standard pharmacies or standard mail order.
Additional Benefits
The DEVOTED CHOICE 005 IN (PPO) plan offers affordable coverage for everyday healthcare needs, featuring no copays and no coinsurance for primary care visits, preventive services, and home health care. For specialist visits and mental health care, members can expect predictable copays ranging from $40 to $50 with no coinsurance. Inpatient hospital stays require a $390 daily copay for the first few days and no copay for the remainder of the stay, while emergency room visits carry a $130 copay that is waived if admitted. This plan also includes valuable supplemental benefits, such as dental care up to a $2,000 annual limit with no copay for preventive services and 0% to 50% coinsurance for comprehensive care. Routine vision exams feature a copay of up to $20 with a $300 annual allowance for eyewear, and routine hearing exams have a $40 copay alongside prescription hearing aid coverage. Additionally, members receive a $100 quarterly allowance for over-the-counter items with no copay or coinsurance, helping to further reduce out-of-pocket health costs.
Inpatient Hospital See details
DEVOTED CHOICE 005 IN (PPO) covers inpatient hospital services with no coinsurance, requiring a $390 daily copay for days 1 through 7 of acute stays and days 1 through 5 of psychiatric stays, with no copay for remaining days. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, and prior authorization is required.
Outpatient Services See details
DEVOTED CHOICE 005 IN (PPO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services, and a $40 copay for outpatient substance abuse individual and group sessions. Outpatient hospital services require a copay ranging from $0 to $475, while outpatient observation services have a $390 copay per stay, with prior authorization required for most of these benefits.
Partial Hospitalization See details
DEVOTED CHOICE 005 IN (PPO) covers partial hospitalization services with a $60.00 copay and no coinsurance. Prior authorization is required to receive this benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE 005 IN (PPO) covers ambulance services with prior authorization, offering ground ambulance services with a copay ranging from no copay to $315 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Transportation services are not covered under this plan.
Emergency Services See details
DEVOTED CHOICE 005 IN (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with a copay ranging from no copay to $45 and no coinsurance. Worldwide emergency services are covered up to a $25,000 maximum, featuring a $130 copay and no coinsurance for emergency or urgent care, and a $315 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE 005 IN (PPO) covers primary care physician services with no copay and no coinsurance, and telehealth benefits with a $0 to $45 copay and no coinsurance. Specialist, mental health, and physical therapy services require a $40 to $50 copay and no coinsurance, while podiatry is not covered, and only some chiropractic services are covered since routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services are covered by DEVOTED CHOICE 005 IN (PPO) with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management training. Additional preventive benefits are partially covered with no copay or coinsurance, excluding services such as in-home support, personal emergency response systems (PERS), and therapeutic massage.
Hearing Services See details
DEVOTED CHOICE 005 IN (PPO) covers routine hearing exams with a $40 copay and no coinsurance, alongside unlimited hearing aid fittings and evaluations. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $399.00 to $699.00 for up to two devices per year, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE 005 IN (PPO) because other eye exam services are not covered, but the plan offers one annual routine eye exam with a $0 to $20 copay and no coinsurance. Covered eyewear, including contacts and eyeglasses, has no copay and no coinsurance up to a $300 combined annual limit.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE 005 IN (PPO) up to a $2,000 annual limit for in- and out-of-network care, featuring no copay and no coinsurance for preventive services, and no copay with 0% to 50% coinsurance for comprehensive services. Medicare-covered dental services require a $40 copay and no coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE 005 IN (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and insulin, are covered with a coinsurance of 0% to 20%, with insulin drugs also requiring a $35 copay.
Dialysis Services See details
Dialysis Services are covered by DEVOTED CHOICE 005 IN (PPO) with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED CHOICE 005 IN (PPO) with no copay, though coinsurance ranges from no coinsurance to 20% and prior authorization is required. Durable medical equipment, prosthetics, and diabetic supplies are covered under this benefit, but diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE 005 IN (PPO) covers diagnostic and radiological services, with prior authorization required for all services. Lab services and outpatient X-rays have no copay, while diagnostic procedures and tests carry no coinsurance and copays ranging from no copay up to $95. Diagnostic radiological services feature copays starting at no copay, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE 005 IN (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered with no copay and no coinsurance under DEVOTED CHOICE 005 IN (PPO) and require prior authorization, though only some services are covered. Standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy for symptomatic peripheral artery disease are not covered.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) care is covered by DEVOTED CHOICE 005 IN (PPO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and additional days beyond the standard 100-day limit are not covered.
Other Services See details
Other services are partially covered under DEVOTED CHOICE 005 IN (PPO), featuring no copay and no coinsurance for additional preventive services and Over-the-Counter (OTC) items up to $100 every three months. Acupuncture and meal benefits are not covered under this plan.
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