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Devoted CHOICE GIVEBACK Indiana (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE GIVEBACK 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 GIVEBACK Indiana (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE GIVEBACK 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 GIVEBACK 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 GIVEBACK 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 GIVEBACK 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. Additionally, this plan comes with a Part B Premium reduction of $142.60. 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 $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 $14000.00 (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 $14000.00 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 Indiana (PPO) plan has a $590 deductible for prescription drugs. In the initial coverage phase, after the deductible is met, you will pay a $10 copay for preferred generic drugs at standard and mail order pharmacies. For standard generic, preferred brand, and non-preferred drugs, you will pay 25% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you will pay nothing for your Part D covered drugs. If you qualify for low-income subsidy (LIS), you will pay no premium for Part D.
Additional Benefits
The Devoted CHOICE GIVEBACK Indiana (PPO) plan offers comprehensive coverage, including inpatient hospital stays with a $350 copay for the first five days and no copay for days 6-90. Outpatient services, emergency services, and primary care visits are covered with varying copays. The plan also provides coverage for hearing, vision, and dental services, with copays and annual maximums for some services. Additional benefits include ambulance services with copays or coinsurance, partial hospitalization with a $70 copay, and home infusion services with a $35 copay for certain drugs and coinsurance for others. The plan also covers medical equipment, dialysis, and home health services, with varying cost-sharing arrangements. However, some services like acupuncture, over-the-counter items, and certain other services are not covered.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with a $350 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered, while non-Medicare covered stays and upgrades for Inpatient Hospital-Acute, and additional days and non-Medicare covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered. Outpatient hospital services have a copay between $0 and $450, observation services have a $400 copay, and ambulatory surgical center services have no copay. Outpatient substance abuse services have a $45 copay for both individual and group sessions, and outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan. There is a $70 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan. Ground ambulance services have a copay between $0 and $350, 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 GIVEBACK Indiana (PPO) plan. Emergency Services has a $110 copay, while Urgently Needed Services has a copay between $0 and $45. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, while Worldwide Emergency Transportation has a $350 copay and 20% coinsurance.
Primary Care See details
The Devoted CHOICE GIVEBACK Indiana (PPO) plan covers primary care physician services, occupational therapy, physician specialist services, mental health specialty services, other health care professionals, psychiatric services, physical therapy and speech-language pathology services, opioid treatment program services, and additional telehealth benefits. Chiropractic services have a $15 copay, occupational therapy services have a $35 copay, physician specialist services have a $50 copay, individual and group mental health and psychiatric sessions have a $45 copay, and physical therapy and speech-language pathology services have a $50 copay. Other health care professionals have a copay between $0 and $50, and opioid treatment program services also have a $45 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services, annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit. 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 are not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $50 copay, fitting/evaluation for hearing aids with no copay, and prescription hearing aids with a copay between $599 and $899. Prescription hearing aids do not cover inner ear, outer ear, or over the ear hearing aids, and OTC hearing aids are not covered.
Vision Services See details
The Devoted CHOICE GIVEBACK Indiana (PPO) plan covers vision services, including routine eye exams with a $20 copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are covered, with a combined maximum benefit of $250 every year for both in-network and out-of-network services.
Dental Services See details
Dental services include coverage for Medicare dental services with a $50 copay, other dental services with a $250 maximum benefit per year, and orthodontic services covered under diagnostic and preventive dental. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis Services are covered under the Devoted CHOICE GIVEBACK Indiana (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 17% coinsurance and no copay, Prosthetic Devices with 0-20% coinsurance and no copay, and Medical Supplies with 20% coinsurance and no copay. 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 with a copay between $0 and $95, and lab services with no copay. Radiological services include a copay for Medicare-covered diagnostic and therapeutic radiological services, with a maximum copay of $300, and coinsurance of at least 20% for therapeutic radiological services. Outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan with no copay and no coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan, but the specific services of 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. There is a copay for Cardiac Rehabilitation Services; however, the specific amount is not detailed.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan, with prior authorization required. For days 1-20 and 61-100, there is no copay, while days 21-60 have a $214 copay. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services are not covered by the Devoted CHOICE GIVEBACK Indiana (PPO) plan, including acupuncture, over-the-counter items, meal benefits, 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.
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