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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 Northwest/North Central 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 $157.70. 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:
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Drug Coverage
The Devoted CHOICE GIVEBACK Indiana (PPO) plan has a $590 deductible for prescription drugs. After meeting the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs at a standard pharmacy or a standard mail order, you'll pay a $5 copay. For standard generic, preferred brand, and non-preferred drugs, you will pay 25% coinsurance. After your total drug costs reach $2000, you will enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Devoted CHOICE GIVEBACK Indiana (PPO) plan offers a wide range of benefits, including coverage for inpatient and outpatient services, with varying copays. This plan includes coverage for primary care, hearing, vision, and dental services. It also covers ambulance, emergency, and home health services. The plan includes coverage for hearing aids, prescription hearing aids, and vision services. Dental services are covered up to an annual maximum of $250. The plan also covers medical equipment, diagnostic and radiological services, and skilled nursing facilities.
Inpatient Hospital See details
The Devoted CHOICE GIVEBACK Indiana (PPO) plan covers Inpatient Hospital services, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For days 1-5 of Inpatient Hospital-Acute and Inpatient Hospital Psychiatric stays, there is a $250 copay, and for days 6-90, there is no copay. 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 not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay between $0 and $350, and observation services with a $350 copay. Ambulatory Surgical Center (ASC) Services have no copay. Outpatient Substance Abuse services, including individual and group sessions, have a copay of $45. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Devoted CHOICE GIVEBACK Indiana (PPO) plan, with a $70 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Devoted CHOICE GIVEBACK Indiana (PPO) plan. Ground ambulance services have a copay between $0 and $350, and air ambulance services have a 20% coinsurance, while transportation services to any health-related location are not covered.
Emergency Services See details
Emergency services are covered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan, with a $110 copay. Urgently needed services have a copay between $0 and $45, and worldwide emergency services are also covered. Worldwide emergency coverage and worldwide urgent coverage have a $110 copay, while 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, and mental health specialty services with a $45 copay for individual or group sessions. The plan also covers other health care professional services with a copay between $0 and $45, psychiatric services with a $45 copay for individual or group sessions, physical therapy and speech-language pathology services with a copay between $45 and $50, additional telehealth benefits with a copay between $0 and $45, and opioid treatment program services with a $45 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services, annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a 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 routine hearing exams with a $45 copay for 1 exam per year, and fitting/evaluation for hearing aids. Prescription hearing aids are covered, with a copay between $599 and $899 for 2 hearing aids per year. Prescription hearing aids - inner ear, outer ear, and over the ear, and OTC hearing aids are not covered.
Vision Services See details
The Devoted CHOICE GIVEBACK Indiana (PPO) plan covers vision services, including routine eye exams with a $20 copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, are also covered. Eyewear has a combined maximum benefit of $250 per year.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $45 copay, while other services are covered up to a $250 annual maximum. 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 are all covered. However, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B insulin drugs with a $35 copay and 18% coinsurance, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and other Medicare Part B drugs with 0-20% coinsurance. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis services are covered under the Devoted CHOICE GIVEBACK Indiana (PPO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 15% coinsurance, and Prosthetics/Medical Supplies with no copay and a coinsurance for Medicare-covered devices and supplies. 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 includes coverage for all diagnostic services, with a copay for Medicare-covered procedures and tests, and no copay for lab services. Diagnostic Radiological Services have a copay up to $300, and Therapeutic Radiological Services have a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan with no copay or coinsurance, but prior authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan, but the plan does not cover any of the sub-services. There is a copay for the covered services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan, but require prior authorization. For days 1-20 and 61-100, there is no copay, but for days 21-60, there is a $214 copay.
Other Services See details
Other Services benefits for the Devoted CHOICE GIVEBACK Indiana (PPO) plan are not covered, including acupuncture, over-the-counter items, and meal benefits, among others. Other services are covered, including $0 preventive services, but the plan does not require authorization or referrals for these additional services.
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