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DEVOTED CHOICE GIVEBACK 006 IN (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 006 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 006 IN (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 006 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 GIVEBACK 006 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 006 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 006 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 $174.90. 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 006 IN (PPO) Medicare plan features an annual drug deductible of $605. Under this plan, there is no copay for Tier 1 preferred generic drugs filled at standard pharmacies or through standard mail order. For Tier 2 generic drugs, copays range from $3.00 for a 1-month supply up to $9.00 for a 3-month supply at standard pharmacies, with mail order options offering a 3-month supply for $7.50. Higher-tier medications are subject to coinsurance rather than flat copays. You will pay a 21% coinsurance for Tier 3 preferred brand drugs through standard pharmacies and mail order. For Tier 4 non-preferred drugs and Tier 5 specialty drugs, the cost sharing is a 25% coinsurance.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 006 IN (PPO) plan offers comprehensive medical coverage with no copay for primary care visits and preventive screenings. Specialist visits require a $45 copay, while inpatient hospital stays incur a daily copay of $425 for the first few days and no copay for the remaining days. Emergency room visits carry a $115 copay, which is waived if you are admitted to the hospital within 24 hours. For ancillary care, members enjoy preventive and comprehensive dental benefits with no copay up to a $250 annual limit, as well as routine eye exams and eyewear. Diagnostic laboratory tests and home health services are also covered with no copay, while skilled nursing facility stays have no copay for the first 20 days. However, this plan does not cover transportation, cardiac rehabilitation, or over-the-counter items.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 006 IN (PPO) partially covers inpatient hospital care with no coinsurance, requiring a daily copay of $425 for days 1 to 5 of acute stays and days 1 to 4 of psychiatric stays, followed by no copay for remaining days. While unlimited additional acute days are covered, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED CHOICE GIVEBACK 006 IN (PPO) with no coinsurance, though prior authorization is required. Members pay no copay for ambulatory surgical center and outpatient blood services, a $45 copay for outpatient substance abuse sessions, $425 per stay for observation services, and between $0 and $525 for outpatient hospital services.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 006 IN (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 006 IN (PPO) covers ground ambulance services with a copay ranging from no copay to $350 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required for both. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Emergency services are covered by DEVOTED CHOICE GIVEBACK 006 IN (PPO) with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no copay to a $40 copay with no coinsurance, while worldwide emergency services are covered up to $25,000 with a $115 copay (and no coinsurance) for emergency or urgent care, and a $350 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 006 IN (PPO) offers primary care physician services with no copay and no coinsurance, while specialist visits require a $45 copay and no coinsurance. Other covered services like physical therapy, occupational therapy, and mental health services have copays ranging from $35 to $50 and no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
DEVOTED CHOICE GIVEBACK 006 IN (PPO) preventive services are covered with no copay and no coinsurance, including annual physical exams, kidney disease education, and routine screenings. Additional preventive benefits are partially covered, as the plan does not cover in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, chemotherapy wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, extra smoking cessation, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
DEVOTED CHOICE GIVEBACK 006 IN (PPO) covers hearing services, including one annual routine exam for a $45 copay and no coinsurance, and unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $599 to $899 for up to two aids per year, though OTC, inner ear, outer ear, and over-the-ear models are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE GIVEBACK 006 IN (PPO) because other eye exam services are not covered, though routine exams are covered with a $0 to $45 copay and no coinsurance. Eyewear is covered with no copay or coinsurance up to a $200 combined annual maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED CHOICE GIVEBACK 006 IN (PPO) covers Medicare-covered dental services with a $45 copay and no coinsurance, and offers other preventive and comprehensive dental services with no copay and no coinsurance up to a $250 annual maximum. Dental benefits are partially covered under this plan, as maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 006 IN (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Associated Medicare Part B drugs, including chemotherapy and radiation, carry a 0% to 20% coinsurance, while covered Part B insulin has a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by DEVOTED CHOICE GIVEBACK 006 IN (PPO) with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 006 IN (PPO) partially covers medical equipment with no copay, requiring 19% coinsurance for durable medical equipment, no coinsurance to 20% coinsurance for prosthetics and medical supplies, and no coinsurance to 19% coinsurance for diabetic supplies. Diabetic therapeutic shoes and inserts are not covered under this plan.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 006 IN (PPO) covers diagnostic and radiological services with prior authorization, offering lab services with no copay and no coinsurance, and diagnostic tests with a $0 to $95 copay and no coinsurance. Diagnostic radiological services have a minimum $0 copay, outpatient X-rays have no copay, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
DEVOTED CHOICE GIVEBACK 006 IN (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the DEVOTED CHOICE GIVEBACK 006 IN (PPO) plan, as all associated sub-services, including intensive cardiac, pulmonary, and SET for PAD rehabilitation, are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 006 IN (PPO) covers Skilled Nursing Facility (SNF) services 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, no prior three-day hospital stay is needed, and additional days beyond the standard 100-day Medicare limit are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 006 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 under this plan.
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