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DEVOTED CHOICE 011 IN (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE 011 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 011 IN (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE 011 IN (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Central Indiana. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE 011 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 011 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 011 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.
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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $6300.00 (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 $6300.00 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 011 IN (PPO) Medicare plan features a $0 drug deductible, meaning your prescription drug coverage begins immediately. Under this plan, you will pay no copay for Tier 1 preferred generic and Tier 2 generic medications when using standard pharmacies or standard mail order for one, two, or three-month supplies. This makes managing everyday prescriptions highly affordable and predictable. For higher-tier medications, costs are based on coinsurance rather than set copays at standard pharmacies and standard mail order. You will pay 20% coinsurance for Tier 3 preferred brand drugs and 25% coinsurance for Tier 4 non-preferred drugs. Tier 5 specialty drugs require a 31% coinsurance for a one-month supply.
Additional Benefits
The DEVOTED CHOICE 011 IN (PPO) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care visits, preventive services, and home health care. Specialist visits and outpatient therapy sessions carry a $30 to $50 copay, while inpatient hospital stays require a $325 daily copay for days 1 through 6 and no copay for days 7 through 90. Emergency room visits have a $150 copay, and outpatient hospital services range from no copay up to a $425 copay, with no coinsurance required for either service. For supplemental care, the plan features dental benefits up to a $3,500 annual maximum with no copay for preventive care and 0% to 50% coinsurance for restorative services. Vision benefits include routine exams with no copay to a $30 copay alongside a $300 annual eyewear allowance, and hearing aids are covered with copays between $399 and $699. Skilled nursing facility stays are also covered with no copay for days 1 through 20 and a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
DEVOTED CHOICE 011 IN (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $325 daily copay for days 1 through 6 and no copay for days 7 through 90. These benefits are partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE 011 IN (PPO) covers outpatient services with no coinsurance, including ambulatory surgical center and blood services with no copay. Other covered services require prior authorization and have copays, ranging from $0 to $425 for outpatient hospital services, $325 per stay for observation services, and $30 per session for outpatient substance abuse treatment.
Partial Hospitalization See details
Partial hospitalization services are covered under the DEVOTED CHOICE 011 IN (PPO) plan with a $60.00 copay and no coinsurance. Prior authorization is required to receive this benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE 011 IN (PPO) covers ambulance services with prior authorization, requiring a copay of no copay to $315 for ground transport and a 20% coinsurance for air transport. While some transportation services are covered, trips to plan-approved or any health-related locations are not covered.
Emergency Services See details
DEVOTED CHOICE 011 IN (PPO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no copay to a $45 copay and no coinsurance, while worldwide emergency services are covered up to a $25,000 lifetime limit with copays ranging from $150 to $315 and 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE 011 IN (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits, psychiatric, and mental health services require a $30 copay and no coinsurance. Physical, occupational, and speech therapy services have a $30 to $50 copay with no coinsurance, but routine chiropractic and podiatry services are not covered. Telehealth benefits are also available with a $0 to $45 copay and no coinsurance.
Preventive Services See details
DEVOTED CHOICE 011 IN (PPO) preventive services are covered with no copay and no coinsurance, including annual physical exams, kidney disease education, glaucoma screenings, and diabetes self-management training. Additional preventive benefits are partially covered with no copay and no coinsurance, but do not cover in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, therapeutic massage, adult day health, palliative care, in-home support, caregiver support, extra smoking cessation, disease management, telemonitoring, remote technologies, and counseling.
Hearing Services See details
DEVOTED CHOICE 011 IN (PPO) hearing services are partially covered, featuring routine hearing exams for a $30 copay and no coinsurance, with no deductible. Up to two prescription hearing aids are covered per year with a copay between $399 and $699 and no coinsurance, but OTC hearing aids and inner ear, outer ear, or over-the-ear prescription models are not covered.
Vision Services See details
Vision Services under DEVOTED CHOICE 011 IN (PPO) are partially covered, offering one routine eye exam per year with a $0 to $30 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and a $300 annual combined maximum benefit for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED CHOICE 011 IN (PPO) partially covers dental services up to a $3,500 annual maximum, offering preventive care and oral surgery with no copay and no coinsurance, and restorative services with no copay and 0% to 50% coinsurance. Medicare-covered dental services require a $30 copay and no coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE 011 IN (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry a coinsurance ranging from no coinsurance to 20%, while covered Part B insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the DEVOTED CHOICE 011 IN (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required to receive these services.
Medical Equipment See details
DEVOTED CHOICE 011 IN (PPO) partially covers medical equipment with no copays, but coinsurance ranges from no coinsurance up to 20% depending on the item. Prior authorization is required for these services, and diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE 011 IN (PPO) covers diagnostic services with prior authorization, offering lab services with no copay, diagnostic tests with a $0 to $95 copay, and no coinsurance. Covered radiological services also require prior authorization, featuring outpatient X-rays and diagnostic radiology starting at a $0 copay, and therapeutic radiology with a 20% coinsurance.
Home Health Services See details
DEVOTED CHOICE 011 IN (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services under DEVOTED CHOICE 011 IN (PPO) feature no coinsurance, but in practice, some services are covered while cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for peripheral artery disease (PAD) are not covered. These non-covered services require prior authorization and carry a $30 copay.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by DEVOTED CHOICE 011 IN (PPO) with no coinsurance, requiring prior authorization but allowing admission without a prior three-day hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by DEVOTED CHOICE 011 IN (PPO), offering over-the-counter (OTC) items and additional preventive services with no copay and no coinsurance. Acupuncture and meal benefits are not covered under this plan.
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