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DEVOTED CHOICE PREMIUM 007 IN (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE PREMIUM 007 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 PREMIUM 007 IN (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE PREMIUM 007 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 PREMIUM 007 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 PREMIUM 007 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 PREMIUM 007 IN (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $10.30. 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 $615.00 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 PREMIUM 007 IN (PPO) Medicare plan features an annual drug deductible of $615. Tier 1 preferred generic drugs are fully covered with no copay for one, two, or three-month supplies at standard pharmacies and standard mail order. For Tier 2 generic medications, standard pharmacy copays range from $3.00 for a one-month supply to $9.00 for a three-month supply, while standard mail order offers a discounted three-month copay of $7.50. Higher-tier prescription drugs under this plan require coinsurance rather than flat copays at standard pharmacies and mail order. Tier 3 preferred brand drugs carry a 22% coinsurance for all supply durations, whereas Tier 4 non-preferred drugs require 25% coinsurance. Tier 5 specialty drugs are limited to a one-month supply and also carry a 25% coinsurance.
Additional Benefits
The DEVOTED CHOICE PREMIUM 007 IN (PPO) plan offers comprehensive medical coverage with no copay for primary care visits, preventive care, and home health services. Specialist visits, physical therapy, and mental health services require a $45 copay, while inpatient hospital stays incur a $390 daily copay for the first 5 to 7 days. Emergency care is covered with a $130 copay, which is waived upon admission, and urgent care visits range from no copay to a $45 copay. For ancillary benefits, the plan features a $3,000 annual dental allowance with no copay for preventive care, plus a $400 yearly limit for eyewear with no copay or deductible. Routine hearing exams carry a $45 copay, while prescription hearing aids require a copay between $199 and $499. Members also benefit from a $125 over-the-counter allowance every three months with no copay or coinsurance.
Inpatient Hospital See details
DEVOTED CHOICE PREMIUM 007 IN (PPO) inpatient hospital services are covered 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 subsequent days. While unlimited additional days are covered for acute care, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE PREMIUM 007 IN (PPO) covers outpatient services with no coinsurance, offering ambulatory surgical center visits and outpatient blood services with no copay. Outpatient hospital services have a copay ranging from $0 to $490, observation services require a $390 copay per stay, and outpatient substance abuse sessions have a $45 copay.
Partial Hospitalization See details
DEVOTED CHOICE PREMIUM 007 IN (PPO) covers partial hospitalization services with a $60.00 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
DEVOTED CHOICE PREMIUM 007 IN (PPO) covers ground ambulance services with a copay ranging from no copay to $315 and no coinsurance, while air ambulance services require a 20% coinsurance and no copay. Prior authorization is required for all ambulance services, and transportation services are not covered.
Emergency Services See details
Emergency services under DEVOTED CHOICE PREMIUM 007 IN (PPO) are covered with a $130 copay and no coinsurance, with the copay waived if admitted to the hospital within 24 hours. Urgently needed services range from no copay to a $45 copay with no coinsurance, and worldwide emergency care is covered up to $25,000 with copays up to $315 and 20% coinsurance for transportation.
Primary Care See details
Primary Care benefits under DEVOTED CHOICE PREMIUM 007 IN (PPO) feature no copay and no coinsurance for primary care visits, while specialist, mental health, and psychiatric services require a $45 copay and no coinsurance. Physical and occupational therapy have a $45 to $50 copay and no coinsurance, telehealth ranges from no copay to a $45 copay with no coinsurance, and podiatry is not covered. Some chiropractic services are covered with a $15 copay and no coinsurance, but routine chiropractic and other chiropractic services are not covered.
Preventive Services See details
DEVOTED CHOICE PREMIUM 007 IN (PPO) covers preventive services with no copay and no coinsurance, including annual physical exams, kidney disease education, and glaucoma screenings. Additional preventive benefits are partially covered, with fitness programs, alternative therapies, and home safety devices included, while services such as personal emergency response systems, in-home support, caregiver support, and therapeutic massage are not covered.
Hearing Services See details
DEVOTED CHOICE PREMIUM 007 IN (PPO) covers hearing services with no deductible, featuring a $45 copay and no coinsurance for routine exams, and prescription hearing aids for a $199 to $499 copay and no coinsurance. Hearing benefits are partially covered, excluding over-the-counter (OTC) hearing aids as well as inner ear, outer ear, and over-the-ear prescription hearing aids.
Vision Services See details
DEVOTED CHOICE PREMIUM 007 IN (PPO) offers partially covered vision services, which include one routine eye exam per year with a $0 to $45 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, up to a combined annual maximum benefit of $400 for contacts, eyeglasses, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE PREMIUM 007 IN (PPO) with an annual maximum of $3,000 for in- and out-of-network benefits, though maxillofacial prosthetics, implant services, and orthodontics are not covered. Medicare-covered dental services require a $45 copay and no coinsurance, while other covered services range from no copay and no coinsurance for preventive care to no copay and 0% to 50% coinsurance for comprehensive care.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED CHOICE PREMIUM 007 IN (PPO) with no copay, requiring prior authorization and carrying a coinsurance ranging from no coinsurance to 20% for Part B chemotherapy, radiation, and other drugs. Covered Part B insulin has a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CHOICE PREMIUM 007 IN (PPO) plan with no copay and a 20% coinsurance, and prior authorization is required.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED CHOICE PREMIUM 007 IN (PPO) with no copay, required prior authorizations, and coinsurance ranging from no coinsurance to 20%. Covered items include durable medical equipment, prosthetics, and diabetic supplies, but diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CHOICE PREMIUM 007 IN (PPO) with prior authorization required. Diagnostic services feature no coinsurance, offering lab services with no copay and other diagnostic tests with a copay between $0 and $95, while radiological services feature no copay for diagnostic and X-ray services and a minimum 20% coinsurance for therapeutic services.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE PREMIUM 007 IN (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered with no coinsurance under the DEVOTED CHOICE PREMIUM 007 IN (PPO) plan with prior authorization required, though only some services are covered in practice. Standard cardiac rehabilitation (with a $40 copay), intensive cardiac rehabilitation (with a $40 copay), pulmonary rehabilitation (with a $35 copay), and supervised exercise therapy for peripheral artery disease (with a $25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE PREMIUM 007 IN (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance and does not require a 3-day prior hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though prior authorization is required and additional days beyond the Medicare limit are not covered.
Other Services See details
DEVOTED CHOICE PREMIUM 007 IN (PPO) partially covers Other Services, offering over-the-counter (OTC) items and additional preventive services with no copay and no coinsurance. The OTC benefit provides up to $125 every three months, but acupuncture and meal benefits are not covered.
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