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DEVOTED CHOICE GIVEBACK 002 IL (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 002 IL (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 002 IL (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 002 IL (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Central Illinois. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 002 IL (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 002 IL (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 002 IL (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 $184.70. 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 002 IL (PPO) plan features an annual drug deductible of $605, but offers significant savings on generic medications. Under this plan, you will pay no copay for Tier 1 preferred generic drugs filled at standard pharmacies or through standard mail order. For Tier 2 generic drugs, copays start at $3.00 for a 1-month supply and go up to $9.00 at standard pharmacies or $7.50 for standard mail order 3-month supplies. For brand-name and specialty medications, your costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 21% coinsurance, while Tier 4 non-preferred drugs require a 25% coinsurance for standard pharmacy and mail order fills. Tier 5 specialty drugs also require a 25% coinsurance and are limited to a 1-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 002 IL (PPO) plan provides comprehensive medical coverage with no coinsurance for many key services, including inpatient hospital stays, outpatient care, and primary doctor visits. Beneficiaries enjoy no copay for primary care visits, preventive screenings, and home health services, while specialist visits require a $45 copay. Inpatient hospital care features a $475 daily copay for days 1 through 4 and no copay for days 5 through 90, while emergency room visits carry a $115 copay that is waived if you are admitted. This plan also includes valuable extra benefits like dental, vision, hearing, and an over-the-counter allowance. Dental services feature no copay for most preventive and comprehensive care up to a $250 annual limit, while eyewear is covered with no copay up to a $200 yearly maximum. Additionally, members receive a $108 over-the-counter credit every three months with no copay, and skilled nursing facility stays require no copay for the first 20 days.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 002 IL (PPO) offers partially covered inpatient hospital care with no coinsurance, requiring a daily copay of $475 for days 1 through 4 and no copay for days 5 through 90. While unlimited additional days are covered for acute care, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 002 IL (PPO) covers outpatient services with no coinsurance, including no copay for ambulatory surgical center and blood services. Outpatient hospital copays range from $0 to $525, observation services cost a $475 copay per stay, and outpatient substance abuse sessions require a $45 copay, with prior authorization required for most services.
Partial Hospitalization See details
Partial hospitalization is covered under the DEVOTED CHOICE GIVEBACK 002 IL (PPO) plan with a $70 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 002 IL (PPO) covers ambulance services with prior authorization, while transportation services are not covered. Ground ambulance services require a copay ranging from no copay to $345 plus coinsurance, and air ambulance services require a 20% coinsurance and a copay.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 002 IL (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 feature no coinsurance and range from no copay to a $40 copay, while worldwide emergency services are covered up to $25,000 with a $115 copay for care and a $345 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
Primary care services under DEVOTED CHOICE GIVEBACK 002 IL (PPO) feature no copay and no coinsurance for primary care physician visits, while specialist visits require a $45 copay and no coinsurance. Other covered care, such as physical therapy, occupational therapy, and psychiatric services, has copays ranging from $0 to $50 with no coinsurance, though routine chiropractic and podiatry services are not covered.
Preventive Services See details
DEVOTED CHOICE GIVEBACK 002 IL (PPO) covers preventive services, annual physical exams, kidney disease education, and other screenings with no copay and no coinsurance. Additional preventive services are partially covered with no copay and no coinsurance, but do not include coverage for in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access technologies, or counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE GIVEBACK 002 IL (PPO), featuring routine exams for a $45 copay and no coinsurance, and up to two prescription hearing aids per year with a $599 to $899 copay and no coinsurance. OTC hearing aids, alongside inner ear, outer ear, and over-the-ear prescription hearing aids, are not covered under this plan.
Vision Services See details
DEVOTED CHOICE GIVEBACK 002 IL (PPO) offers partially covered vision services, as other eye exam services are not covered. Routine eye exams are covered with a $0 to $20 copay and no coinsurance, while eyewear is covered with no copay, no coinsurance, and a $200 annual maximum benefit.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE GIVEBACK 002 IL (PPO), featuring no copay and no coinsurance for most preventive and comprehensive services up to a $250 annual limit, while Medicare-covered dental services require a $45 copay and no coinsurance. Implant services, maxillofacial prosthetics, and orthodontics are not covered under this plan.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 002 IL (PPO) covers home infusion bundled services with no copay, although prior authorization is required. Associated Medicare Part B drugs, including chemotherapy, radiation, and other drugs, carry a coinsurance ranging from no coinsurance to 20%, while Part B insulin drugs require a $35 copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CHOICE GIVEBACK 002 IL (PPO) plan with no copay and 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 002 IL (PPO) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment has a 15% coinsurance (with no copay), while prosthetics and medical supplies carry no copay and range from no coinsurance to 20% coinsurance. Diabetic equipment is partially covered with no copay and no coinsurance to 15% coinsurance for supplies, but diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the DEVOTED CHOICE GIVEBACK 002 IL (PPO) plan, with prior authorization required. Diagnostic services feature no coinsurance, with no copay for lab services and a $0 to $95 copay for procedures, while radiological services include no-copay X-rays and a minimum 20% coinsurance for therapeutic services.
Home Health Services See details
DEVOTED CHOICE GIVEBACK 002 IL (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 by DEVOTED CHOICE GIVEBACK 002 IL (PPO) with no copay and no coinsurance, meaning some services are covered, but standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 002 IL (PPO) covers Skilled Nursing Facility (SNF) services 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, and any additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 002 IL (PPO) partially covers other services, including over-the-counter (OTC) items up to $108 every three months and additional preventive services, both with no copay and no coinsurance. Acupuncture, meal benefits, and dual-eligible SNP services are not covered.
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