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DEVOTED CHOICE 003 IL (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE 003 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 003 IL (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE 003 IL (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Greater Rockford. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE 003 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 003 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 003 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.
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 a $385.00 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 $6200.00 (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 $6200.00 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 003 IL (PPO) Medicare plan features an annual prescription drug deductible of $385. Under this plan, there is no copay for Tier 1 preferred generic and Tier 2 generic medications filled at standard pharmacies or through standard mail-order services. This ensures that essential generic prescriptions remain highly affordable with zero out-of-pocket costs during the initial coverage phase. For brand-name and specialty medications, your costs are determined by a percentage of the drug cost rather than a flat copayment. You will pay a 19% coinsurance for Tier 3 preferred brand drugs and a 25% coinsurance for Tier 4 non-preferred drugs at standard pharmacies and mail-order options. Tier 5 specialty tier drugs require a 27% coinsurance for a one-month supply.
Additional Benefits
The DEVOTED CHOICE 003 IL (PPO) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care visits, preventive services, and home health care. For inpatient hospital stays, members pay no coinsurance and a $325 daily copay for days 1 through 7, followed by no copay for days 8 through 90. Outpatient hospital services feature no coinsurance with copays ranging from no copay up to $425, while emergency room visits require a $150 copay that is waived if admitted. Specialist visits require a $30 to $50 copay, and dental services are covered up to a $3,000 annual limit with no copay and up to 50% coinsurance for most care. Vision benefits include a routine exam and up to $200 annually for eyewear with no copay, coinsurance, or deductible, while hearing aids require a $399 to $699 copay. Durable medical equipment carries a 20% to 30% coinsurance with no copay, and Part B drugs require up to 20% coinsurance.
Inpatient Hospital See details
DEVOTED CHOICE 003 IL (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $325 daily copay for days 1 through 7 and no copay for days 8 through 90. While unlimited additional days are covered for acute stays, this benefit is partially covered as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE 003 IL (PPO) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and blood services. Outpatient hospital services require a copay ranging from $0 to $425 ($325 per stay for observation services), while outpatient substance abuse sessions carry a $30 copay, with prior authorization required for most benefits.
Partial Hospitalization See details
DEVOTED CHOICE 003 IL (PPO) covers partial hospitalization services with a $60.00 copay and no coinsurance. Prior authorization is required to access this covered benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by DEVOTED CHOICE 003 IL (PPO), featuring a ground ambulance copay of $0 to $330 with no coinsurance, and a 20% coinsurance with no copay for air ambulance services. Prior authorization is required for ambulance services, and although some transportation services are covered, trips to plan-approved or any health-related locations are not covered.
Emergency Services See details
DEVOTED CHOICE 003 IL (PPO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with no coinsurance and a copay ranging from no copay to $45. Worldwide emergency services are covered up to $25,000, featuring a $150 copay (no coinsurance) for emergency and urgent care, and a $330 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE 003 IL (PPO) covers primary care physician services with no copay and no coinsurance, while specialists and therapy services require copays ranging from $30 to $50 with no coinsurance. This benefit is partially covered, as podiatry services, routine chiropractic care, and other chiropractic services are not covered.
Preventive Services See details
DEVOTED CHOICE 003 IL (PPO) covers preventive services, annual physical exams, and kidney disease education with no copay and no coinsurance. Additional preventive benefits are partially covered with no copay or coinsurance, but do not cover in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs for hair loss, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE 003 IL (PPO), offering routine exams for a $30 copay and no coinsurance, and up to two prescription hearing aids per year for a $399 to $699 copay with no coinsurance. 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 003 IL (PPO) covers vision services, offering one routine eye exam per year with a $0 to $30 copay and no coinsurance, though other eye exam services are not covered. Eyewear, including contacts and eyeglasses, is covered with no copay, no coinsurance, and no deductible, up to a combined maximum benefit of $200 per year.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE 003 IL (PPO) with a $3,000 annual maximum for both in-network and out-of-network care, excluding maxillofacial prosthetics, implant services, and orthodontics. Medicare-covered dental services require a $30 copay and no coinsurance, while other covered dental services have no copay and between no coinsurance and 50% coinsurance.
Home Infusion bundled Services See details
DEVOTED CHOICE 003 IL (PPO) covers Home Infusion bundled Services with no copay, subject to prior authorization. Associated Medicare Part B chemotherapy, radiation, and other drugs require no coinsurance to 20% coinsurance, while Part B insulin drugs have a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by DEVOTED CHOICE 003 IL (PPO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
DEVOTED CHOICE 003 IL (PPO) covers medical equipment with no copay, though prior authorization is required. Durable medical equipment carries a 20% to 30% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance to 20% or 30% coinsurance. Diabetic equipment is partially covered, as diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE 003 IL (PPO) covers diagnostic and radiological services with prior authorization, offering diagnostic lab services and outpatient X-rays with no copay. Diagnostic procedures and tests have a copay ranging from $0 to $95 with no coinsurance, while diagnostic radiological services have no copay and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
DEVOTED CHOICE 003 IL (PPO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE 003 IL (PPO) does not provide coverage for Cardiac Rehabilitation Services, as all associated sub-services—including standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD)—are not covered by the plan.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by DEVOTED CHOICE 003 IL (PPO) with no coinsurance and requires no prior three-day hospital stay, though prior authorization is needed. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, while additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED CHOICE 003 IL (PPO) partially covers other services, offering over-the-counter (OTC) items up to $100 every three months and additional preventive services with no copay and no coinsurance. Acupuncture and meal benefits are not covered.
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