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Devoted CHOICE GIVEBACK Illinois (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE GIVEBACK Illinois (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 Illinois (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE GIVEBACK Illinois (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Springfield. The overall rating for this plan is not yet available for 2025.
It's important to know that Devoted CHOICE GIVEBACK Illinois (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 Illinois (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 Illinois (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 $117.60. 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 Illinois (PPO) plan has a $590 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance for your medications depending on the drug tier and pharmacy. For example, you'll pay a $10 copay for preferred generic drugs at a standard or mail-order pharmacy. For standard generic drugs, preferred brand drugs, and non-preferred drugs, you'll pay 25% coinsurance at standard and mail-order pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Devoted CHOICE GIVEBACK Illinois (PPO) plan offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays. It also covers primary care, preventive, hearing, vision, and dental services, with specific copays or no copays for certain services. Additional benefits include ambulance, emergency, and home health services, along with coverage for medical equipment and home infusion. However, certain services like cardiac rehabilitation, additional hours of care, and some dental procedures are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with a copay of $425 for days 1-4, and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered, including all outpatient hospital services, with a copay of $0-$575 for outpatient hospital services and $475 for observation services. Ambulatory Surgical Center (ASC) Services have no copay, and Outpatient Substance Abuse Services have a $45 copay for both individual and group sessions. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Devoted CHOICE GIVEBACK Illinois (PPO) plan and requires prior authorization. You will have a $70 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE GIVEBACK Illinois (PPO) plan, with prior authorization required for all ambulance services. Ground ambulance services have a copay between $0 and $350, while air ambulance services have a 20% coinsurance; however, transportation services to plan-approved and any health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Devoted CHOICE GIVEBACK Illinois (PPO) plan. Emergency Services have a $110 copay, and Urgently Needed Services have a copay between $0 and $45. Worldwide Emergency Services has a $110 copay for Worldwide Emergency Coverage and Worldwide Urgent Coverage, and Worldwide Emergency Transportation has a 20% coinsurance and a $350 copay.
Primary Care See details
The Devoted CHOICE GIVEBACK Illinois (PPO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $15 copay, occupational therapy services have a $35 copay, physician specialist services have a $45 copay, individual and group sessions for mental health and psychiatric services have a $45 copay, physical therapy and speech-language pathology services have a $45-$50 copay, additional telehealth benefits have a $0-$45 copay, and opioid treatment program services have a $45 copay. Routine chiropractic care is not covered, and podiatry services are not covered.
Preventive Services See details
The Devoted CHOICE GIVEBACK Illinois (PPO) plan covers preventive services including annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs, with no copay or coinsurance. In-home safety assessment, personal emergency response systems (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 hearing exams with a $45 copay, and routine hearing exams covered once per year. Prescription hearing aids are covered with a copay between $599 and $899 for all types of hearing aids, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision services include coverage for routine eye exams with a $45 copay, and eyewear, with a combined maximum benefit of $250 per year for both in-network and out-of-network services, as well as contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, all with no copay.
Dental Services See details
Dental services include coverage for Medicare dental services with a $45 copay, other dental services, oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery; however, maxillofacial prosthetics, implant services, and orthodontics are not covered. This plan covers up to $250 per year for dental services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay, and a 20% coinsurance; for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE GIVEBACK Illinois (PPO) plan with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME) with an 18% coinsurance and no copay, Prosthetic Devices with 0-20% coinsurance and no copay, and Medical Supplies with a 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 are covered, including Diagnostic Procedures/Tests with a copay between $0 and $95, Lab Services with no copay, and Outpatient X-Ray Services with no copay. Diagnostic Radiological Services have a copay of at most $300, while Therapeutic Radiological Services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK Illinois (PPO) plan with no copay or 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 not covered by the Devoted CHOICE GIVEBACK Illinois (PPO) plan. Although the plan covers the benefit, it does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE GIVEBACK Illinois (PPO) plan. For days 1-20 and 61-100, there is no copay, and for days 21-60, the copay is $214.
Other Services See details
Other Services are not covered by the Devoted CHOICE GIVEBACK Illinois (PPO) plan, including acupuncture, over-the-counter items, meal benefits, and other services. The plan does cover Other 2 benefits, including $0 preventive services.
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