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DEVOTED CHOICE GIVEBACK 009 IN (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 009 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 009 IN (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 009 IN (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 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 009 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 009 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 009 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 $158.10. 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 009 IN (PPO) Medicare plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs are highly affordable, featuring no copay for up to a three-month supply filled through standard pharmacies or standard mail order. Tier 2 generic medications require a low copay starting at $3.00 for a one-month supply, which goes up to $9.00 at standard pharmacies or $7.50 via standard mail order for a three-month supply. For higher-tier medications, cost-sharing is structured as coinsurance. Tier 3 preferred brand drugs carry a 21% coinsurance for all supply durations at standard pharmacies and mail order. Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance, with specialty tier medications limited to a one-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 009 IN (PPO) plan offers robust medical coverage with no copay and no coinsurance for primary care visits, while specialist visits require a $50 copay. Inpatient hospital stays feature a $425 daily copay for the first few days and no copay for subsequent days, while outpatient hospital services range from no copay to a $525 copay. Emergency care is accessible with a $115 copay that is waived upon admission, and urgent care incurs no copay to a $40 copay. Standard dental services and eyewear are highly affordable, featuring no copay and no coinsurance up to yearly limits of $250 and $200 respectively. Home health services require no copay, while skilled nursing facilities offer no copay for the first 20 days followed by a $218 daily copay. Diagnostic labs and routine preventive services also feature no copay, though certain specialized services like dialysis and durable medical equipment require up to 20% coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits under DEVOTED CHOICE GIVEBACK 009 IN (PPO) are covered with no coinsurance, requiring a daily copay of $425 for days 1-5 of acute stays and days 1-4 of psychiatric stays, and no copay for later days. Additional days for acute stays are unlimited, but non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 009 IN (PPO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services, and a $50 copay for outpatient substance abuse sessions. Outpatient hospital services have a copay ranging from $0 to $525, while observation services require a $425 copay per stay, with prior authorization required for most benefits.
Partial Hospitalization See details
Partial hospitalization is covered under the DEVOTED CHOICE GIVEBACK 009 IN (PPO) plan with a $70.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 009 IN (PPO) covers ambulance services with prior authorization, offering ground services with no coinsurance and a copay ranging from no copay to $350, and air services with a 20% coinsurance and no copay. Transportation services are not covered.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 009 IN (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require no copay to a $40 copay and 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 and 20% coinsurance for transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 009 IN (PPO) offers primary care physician services with no copay and no coinsurance, while specialist visits require a $50 copay and no coinsurance. Therapy, mental health, psychiatric, and telehealth services are covered with copays ranging from $0 to $50 and no coinsurance, but podiatry is not covered and chiropractic services are only partially covered as routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by DEVOTED CHOICE GIVEBACK 009 IN (PPO) with no copay and no coinsurance for covered services like annual physical exams, fitness benefits, and nutritional counseling. However, several sub-services are not covered under this plan, including in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, therapeutic massage, and in-home support services.
Hearing Services See details
Hearing Services are partially covered by DEVOTED CHOICE GIVEBACK 009 IN (PPO), featuring routine hearing exams for a $50 copay and no coinsurance, and prescription hearing aids for a $599 to $899 copay and no coinsurance. OTC hearing aids, along with inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
DEVOTED CHOICE GIVEBACK 009 IN (PPO) partially covers vision services, offering one routine eye exam annually with a $0 to $50 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible up to a $200 combined yearly limit for contacts, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE GIVEBACK 009 IN (PPO), offering most preventive and comprehensive services with no copay and no coinsurance up to a $250 yearly limit, while Medicare-covered dental requires a $50 copay and no coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 009 IN (PPO) covers Home Infusion bundled Services with no copay, though prior authorization and step therapy are required. Medicare Part B chemotherapy, radiation, and other drugs have no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CHOICE GIVEBACK 009 IN (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 009 IN (PPO) covers durable medical equipment, prosthetics, and diabetic supplies with no copay and coinsurance ranging from no coinsurance to 20%. This benefit is partially covered as diabetic therapeutic shoes and inserts are not covered, and prior authorization is required for equipment and supplies.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CHOICE GIVEBACK 009 IN (PPO) with prior authorization required. Lab services and outpatient X-rays have no copay, diagnostic procedures and tests have no coinsurance with copays ranging from $0 to $95, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home health services are covered under the DEVOTED CHOICE GIVEBACK 009 IN (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED CHOICE GIVEBACK 009 IN (PPO) with no coinsurance, though prior authorization is required. While some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered in practice, with copayments for these services ranging from $20 to $30.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by DEVOTED CHOICE GIVEBACK 009 IN (PPO) 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, though a prior three-day inpatient hospital stay is not, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 009 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.
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