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Devoted CHOICE PLUS Indiana (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE PLUS 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 PLUS Indiana (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE PLUS 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 PLUS 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 PLUS 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 PLUS Indiana (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $49.60. 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 PLUS 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 you use. For example, you will pay a $5 copay for preferred generic drugs at a standard pharmacy, or 25% coinsurance for standard generic drugs. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase and pay nothing for covered drugs. This plan also offers a Part D premium reduction if you qualify for the low-income subsidy.
Additional Benefits
The Devoted CHOICE PLUS Indiana (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient hospital services with varying copays. Emergency, primary care, and preventive services are also covered, often with no copay. The plan includes coverage for hearing and vision services, with copays for exams and coverage for hearing aids and eyewear. Dental services are covered with a $1,250 annual maximum. The plan also covers home health services, dialysis, and medical equipment with some coinsurance and copayments.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you'll pay a $390 copay for days 1-7, and no copay for days 8-90. For Inpatient Hospital Psychiatric, you'll pay a $390 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered Stay for Inpatient Hospital-Acute and Upgrades for Inpatient Hospital-Acute are not covered, and Additional Days for Inpatient Hospital Psychiatric and Non-Medicare-covered Stay 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 $490; Observation Services with a $390 copay; and Ambulatory Surgical Center (ASC) Services with 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 by the Devoted CHOICE PLUS Indiana (PPO) plan, with a $60 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE PLUS Indiana (PPO) plan. 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 under the Devoted CHOICE PLUS Indiana (PPO) plan. Emergency Services have a $125 copay, and no coinsurance, while Urgently Needed Services have a copay between $0 and $45, and no coinsurance. Worldwide Emergency Transportation has a $300 copay and 20% coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 copay and no coinsurance.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services with no copay, Chiropractic Services with a $20 copay for routine care, 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. Also covered are Other Health Care Professional with a copay between $0 and $45, Psychiatric Services with a $45 copay for individual and 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. Podiatry Services are not covered.
Preventive Services See details
The Devoted CHOICE PLUS Indiana (PPO) plan covers preventive services, including annual physical exams and additional preventive services like health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, Home and Bathroom Safety Devices and Modifications, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. However, the plan does not cover 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, and Counseling Services.
Hearing Services See details
Hearing Services include hearing exams with a $35 copay, and prescription hearing aids with a copay between $199 and $499. Fitting/Evaluation for Hearing Aids, and Prescription Hearing Aids (all types) are covered. Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear, as well as OTC Hearing Aids are not covered.
Vision Services See details
Vision Services include eye exams with a $35 copay, and eyewear with a combined maximum plan benefit coverage of $1250 every year for both in-network and out-of-network services. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The Devoted CHOICE PLUS Indiana (PPO) plan covers dental services with a $1,250 annual maximum. Medicare dental services have a $45 copay, while other services such as Oral Exams, Dental X-Rays, and Prophylaxis (Cleaning) are covered with no copay. However, Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE PLUS Indiana (PPO) plan. The coinsurance for this service is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance of 0% to 20%, Prosthetic Devices with a coinsurance of 0% to 20%, and Medical Supplies with a 20% coinsurance, but does not cover DME for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures/tests (with a copay between $0 and $95), lab services (with no copay), and outpatient X-ray services (with no copay). Diagnostic Radiological Services have a maximum copay of $300, and Therapeutic Radiological Services have a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Devoted CHOICE PLUS Indiana (PPO) with no copay and no coinsurance; however, Additional Hours of Care and Personal Care Services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Devoted CHOICE PLUS Indiana (PPO) plan. However, Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are not covered.
Skilled Nursing Facility (SNF) See details
The Devoted CHOICE PLUS Indiana (PPO) plan covers Skilled Nursing Facility (SNF) services, but requires prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214 per day; additional days beyond Medicare-covered SNF stays and non-Medicare-covered stays are not covered.
Other Services See details
The Devoted CHOICE PLUS Indiana (PPO) plan does not cover acupuncture, over-the-counter items, or meal benefits. Additionally, it does not cover 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.
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