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Devoted CHOICE Indiana (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE 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 Indiana (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE Indiana (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 2025.
It's important to know that Devoted CHOICE 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 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 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.
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 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 $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:
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Drug Coverage
The Devoted CHOICE Indiana (PPO) plan has an enhanced alternative drug benefit. The plan has a $590 deductible. During the initial coverage phase, after you pay the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy type. For example, you may pay a $5 copay for a preferred generic drug at a standard or mail order pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for your drugs.
Additional Benefits
The Devoted CHOICE Indiana (PPO) plan offers a range of benefits, including inpatient and outpatient hospital services with varying copays. You'll find coverage for primary care, hearing, vision, and dental services, each with specific copays or cost-sharing arrangements, such as a $40 copay for eye exams and a $45 copay for some dental services. This plan also includes coverage for ambulance and emergency services, along with preventive services at no copay, and home health services with no copay or coinsurance. However, it's important to note that certain services like cardiac rehabilitation, some dental procedures, and some "other services" are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you will pay a copay of $390 for days 1-7, and no copay for days 8-90; for Inpatient Hospital Psychiatric, you will pay a copay of $390 for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with copays ranging from $0 to $490, observation services with a $390 copay, and outpatient substance abuse services with a $45 copay for both individual and group sessions. Ambulatory Surgical Center (ASC) Services have no copay, and outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You will have a $60 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Devoted CHOICE Indiana (PPO). Ground ambulance services have a copay between $0 and $300, while air ambulance services have a 20% coinsurance. 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. Emergency Services have a $125 copay, while Urgently Needed Services have a copay between $0 and $45. Worldwide Emergency Transportation has a 20% coinsurance and a $300 copay, and Worldwide Emergency Coverage and Worldwide Urgent Coverage both have a $125 copay.
Primary Care See details
The Devoted CHOICE Indiana (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $45 copay, physician specialist services with a $45 copay, and mental health specialty services with a $45 copay for individual and group sessions. Physical therapy and speech-language pathology services have a copay between $45 and $50, and additional telehealth benefits have a copay between $0 and $45. Opioid Treatment Program Services have a $45 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive services, including Medicare-covered services, annual physical exams, and additional preventive services are covered. The plan also covers Health Education, Weight Management Programs, Alternative Therapies, Nutritional/Dietary Benefit, Fitness Benefit, Home and Bathroom Safety Devices and Modifications, Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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 (including Web/Phone-based technologies and Nursing Hotline), and Counseling Services are not covered.
Hearing Services See details
Hearing services include hearing exams with a $40 copay, and routine hearing exams limited to one per year, and fitting/evaluation for hearing aids which is unlimited. Prescription hearing aids are covered with a copay between $399 and $699, but 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 $40 copay. Eyewear is covered with a combined maximum of $1000 per year for both in-network and out-of-network services.
Dental Services See details
The Devoted CHOICE Indiana (PPO) plan covers Medicare Dental Services with a $45 copay, and other dental services including oral exams, dental x-rays, and more, with a maximum benefit of $1000 per year. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, you will pay a $35 copay and 20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, you will pay between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE Indiana (PPO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 0-20% coinsurance and no copay, Prosthetic Devices with 0-20% coinsurance and no copay, and Medical Supplies with 20% coinsurance and no copay. 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, diagnostic procedures and tests (with a copay between $0 and $95), lab services (no copay), all radiological services, diagnostic radiological services (with a copay of at most $300), therapeutic radiological services (with coinsurance of at least 20%), and outpatient X-ray services (no copay). Prior authorization is required for all diagnostic and radiological services.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE Indiana (PPO) plan with no copay or coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted CHOICE Indiana (PPO) plan. Although the plan covers Cardiac Rehabilitation Services, none of the sub-services are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE Indiana (PPO) plan, but require prior authorization. There is no copay for days 1-20 and 61-100, and a $214 copay for days 21-60. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Devoted CHOICE Indiana (PPO) plan does not cover acupuncture, over-the-counter items, meal benefits, dual eligible SNPs with highly integrated services, 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, or Self-Directed Personal Assistance Services. Some "Other Services" are covered, including preventive services with no copay.
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