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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 Southeast and Louisville-Jeffersonville 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 deductible of $590. In the initial coverage phase, after you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, in the initial coverage phase, you will pay a $10 copay for preferred generic drugs at a standard or mail-order pharmacy. For standard generic, preferred brand, and non-preferred drugs, you will pay 25% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, and you will pay nothing for your Part D covered drugs.
Additional Benefits
The Devoted CHOICE Indiana (PPO) plan offers a range of benefits with varying costs. Hospital stays have a copay of $390 for the first 5 days, and then no copay for the remaining days. Outpatient services, emergency services, and primary care visits have copays ranging from $0 to $125. This plan also includes coverage for hearing and vision services. Hearing exams have a $50 copay, and the plan covers hearing aids with a copay between $399 and $699. Vision services include eye exams with a $50 copay, and eyewear with a maximum benefit of $1,000 per year. Dental services are covered with a $50 copay for Medicare-covered services and a $1,000 annual benefit for other dental services.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with prior authorization. For days 1-5, there is a $390 copay, and for days 6-90, there is no copay. Additional Days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services with a copay between $0 and $490, observation services with a $390 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a $50 copay for individual and group sessions, and outpatient blood services.
Partial Hospitalization See details
Partial Hospitalization is covered under the Devoted CHOICE Indiana (PPO) plan, and requires prior authorization. You will have a $60 copay for this service.
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 by the Devoted CHOICE Indiana (PPO) plan. Emergency Services has a $125 copay, while Urgently Needed Services has a copay between $0 and $50. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 copay, and Worldwide Emergency Transportation has a $300 copay and 20% coinsurance.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Chiropractic Services have a $20 copay, Occupational Therapy Services have a $45 copay, Physician Specialist Services have a $50 copay, Individual and Group Sessions for Mental Health Specialty Services have a $50 copay, Other Health Care Professional services have a copay between $0 and $50, Individual and Group Sessions for Psychiatric Services have a $50 copay, Physical Therapy and Speech-Language Pathology Services have a $50 copay, Additional Telehealth Benefits have a copay between $0 and $50, and Opioid Treatment Program Services have a $50 copay. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive services, including Medicare-covered services, annual physical exams, and other preventive services, are covered. Some additional preventive services, such as In-Home Safety Assessment, Personal Emergency Response System, Medical Nutrition Therapy, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Telemonitoring Services, Remote Access Technologies, and Counseling Services are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $50 copay, and the plan covers routine hearing exams once per year and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a copay between $399 and $699 for two visits per year, but prescription hearing aids for the inner ear, outer ear, 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 $50 copay, and eyewear with a combined maximum benefit of $1,000 every year for both in-network and out-of-network services. This plan also covers contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
Dental services include coverage for Medicare dental services with a $50 copay, and other dental services with a $1,000 maximum benefit per year. Some services, such as maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 20% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Devoted CHOICE Indiana (PPO) plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics, Medical Supplies, and Diabetic Equipment. DME has a coinsurance of 0% to 20%, while Prosthetic Devices have a coinsurance of 0% to 20%, and Medical Supplies have a 20% coinsurance. 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/tests (with a copay between $0 and $95), lab services (with no copay), all radiological services, diagnostic radiological services (with a copay up to $300), therapeutic radiological services (with a coinsurance of at least 20%), and outpatient X-ray services (with no copay). All services require prior authorization.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE Indiana (PPO) plan with no copay and no coinsurance, but 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 not covered by the Devoted CHOICE Indiana (PPO) plan. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE Indiana (PPO) plan, but prior authorization is required. For days 1-20 and days 61-100, there is no copay, and for days 21-60, the copay is $214.
Other Services See details
The Devoted CHOICE Indiana (PPO) plan does not cover acupuncture, over-the-counter (OTC) 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, and Self-Directed Personal Assistance Services. Other services like "Other 2" and "Other Services" are covered.
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