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DEVOTED CHOICE GIVEBACK 012 IN (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 012 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 012 IN (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 012 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 GIVEBACK 012 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 012 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 012 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 $159.90. 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 012 IN (PPO) Medicare plan features an annual drug deductible of $605. Under this plan, you will pay no copay for Tier 1 preferred generic medications obtained through standard pharmacies or standard mail order. Tier 2 generic drugs are also highly affordable, with copays starting at just $3.00 for a one-month supply. For higher-tier medications, cost-sharing transitions to a percentage of the drug cost. Tier 3 preferred brand drugs require a 21% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs carry a 25% coinsurance for standard pharmacy and mail-order services.
Additional Benefits
The Devoted Choice Giveback 012 IN (PPO) plan offers comprehensive medical coverage with no copay for primary care visits, while specialist visits require a $55 copay. For hospital stays, inpatient services feature no copay for days 5 through 90, though a $475 daily copay applies for the first 4 days. Emergency care is also accessible with a $115 copay, which is waived if you are admitted to the hospital within 24 hours. Routine preventive care, home health services, and select dental and vision benefits are covered with no copays or coinsurance, including up to a $200 annual limit for eyewear. Routine hearing exams require a $55 copay, while prescription hearing aids are covered with copays ranging from $599 to $899. Skilled nursing facility stays are also covered with no copay for the first 20 days.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 012 IN (PPO) covers inpatient acute and psychiatric hospital services with no coinsurance, requiring a $475 daily copay for days 1 through 4 and no copay for days 5 through 90. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED CHOICE GIVEBACK 012 IN (PPO) with no coinsurance, featuring no copays for ambulatory surgical center and blood services. Outpatient hospital services require a $0 to $575 copay, observation services require a $475 copay per stay, and outpatient substance abuse sessions carry a $50 copay.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 012 IN (PPO) offers coverage for partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to access these benefits.
Ambulance and Transportation Services See details
Ambulance services are covered by DEVOTED CHOICE GIVEBACK 012 IN (PPO) with prior authorization, requiring a copay of $0 to $315 (with no coinsurance) for ground transport and a 20% coinsurance (with no copay) for air transport. Transportation services to health-related locations are not covered.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 012 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 a $25,000 limit with copays ranging from $115 to $315 and 20% coinsurance for worldwide emergency transportation.
Primary Care See details
Primary care services under the DEVOTED CHOICE GIVEBACK 012 IN (PPO) plan feature no copay and no coinsurance for primary care provider visits, while specialist visits require a $55 copay and no coinsurance. Covered therapy services, including occupational therapy ($35 copay) and physical or speech therapy ($55 copay), also feature no coinsurance, whereas chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive Services are partially covered under the DEVOTED CHOICE GIVEBACK 012 IN (PPO) plan with no copay and no coinsurance for covered care, such as annual physical exams, fitness benefits, and nutritional counseling. However, several supplemental services are not covered, including in-home safety assessments, personal emergency response systems (PERS), therapeutic massages, and medical nutrition therapy.
Hearing Services See details
DEVOTED CHOICE GIVEBACK 012 IN (PPO) hearing services are partially covered, featuring a $55 copay and no coinsurance for routine exams, plus a $599 to $899 copay and no coinsurance for up to two prescription hearing aids per year. There is no deductible for these services, but OTC hearing aids as well as inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
DEVOTED CHOICE GIVEBACK 012 IN (PPO) offers partially covered vision services, featuring one routine eye exam per year with a $0 to $55 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay or coinsurance up to a $200 annual maximum benefit for contacts, lenses, frames, and upgrades.
Dental Services See details
DEVOTED CHOICE GIVEBACK 012 IN (PPO) offers partially covered dental services, with Medicare-covered dental requiring a $55 copay and no coinsurance, and other covered services having no copay and no coinsurance up to a $250 annual maximum. Most preventive and comprehensive services have no copay and no coinsurance, though maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 012 IN (PPO) covers home infusion bundled services with no copay and no coinsurance, with prior authorization required. Medicare Part B chemotherapy, radiation, and other drugs have no copay and no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 012 IN (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Medical equipment is covered by DEVOTED CHOICE GIVEBACK 012 IN (PPO) with no copays, although prior authorization is required and coinsurance applies. Durable medical equipment has a 19% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance up to 20% coinsurance. Diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 012 IN (PPO) covers diagnostic and radiological services with prior authorization required. Lab services and outpatient X-rays have no copay, diagnostic procedures and tests have no coinsurance and copays ranging from $0 to $95, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
DEVOTED CHOICE GIVEBACK 012 IN (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered with no coinsurance under the DEVOTED CHOICE GIVEBACK 012 IN (PPO) plan, though only some services are covered in practice. Specifically, standard cardiac rehabilitation (with a $30 copay), intensive cardiac rehabilitation (with a $30 copay), pulmonary rehabilitation (with a $25 copay), and supervised exercise therapy for symptomatic peripheral artery disease (with a $20 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by DEVOTED CHOICE GIVEBACK 012 IN (PPO) with no coinsurance, requiring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not needed, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 012 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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