A non-government entity
DEVOTED CHOICE GIVEBACK 004 IL (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 004 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 004 IL (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 004 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 GIVEBACK 004 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 004 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 004 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:
Sign up for DEVOTED CHOICE GIVEBACK 004 IL (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The DEVOTED CHOICE GIVEBACK 004 IL (PPO) Medicare plan has a $605 prescription drug deductible. For Tier 1 preferred generic medications, there is no copay for one-month, two-month, or three-month supplies filled at standard pharmacies or through standard mail order. Tier 2 generic drugs are also budget-friendly, costing a $3.00 copay for a one-month supply at standard pharmacies and standard mail order. Brand-name and specialty medications are subject to coinsurance under this plan, starting with a 21% coinsurance for Tier 3 preferred brand drugs. Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance at standard pharmacies and standard mail order. These tiered pricing structures allow members to easily anticipate their out-of-pocket prescription costs.
Additional Benefits
The Devoted Choice Giveback 004 IL (PPO) plan offers robust core medical coverage with no copay or coinsurance for primary care visits, home health services, and laboratory tests. For specialist visits, patients will pay a copay ranging from $35 to $50, while inpatient hospital stays require a $475 daily copay for the first four days and no copay thereafter. Emergency room visits carry a $115 copay that is waived upon admission, though some specialized services like dialysis and durable medical equipment require a 15% to 20% coinsurance. This plan also includes key preventive and routine benefits to help you manage your everyday health with minimal out-of-pocket costs. Routine vision exams feature a low copay of up to $20 alongside a $200 annual allowance for eyewear, while covered dental services offer no copay up to a $250 yearly maximum. Additionally, members benefit from a $94 over-the-counter allowance every three months and no copay for annual physicals and fitness programs.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 004 IL (PPO) covers inpatient hospital care 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, as prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 004 IL (PPO) covers outpatient services with no coinsurance, though prior authorization is required for most care. Patients will pay a copay of $0 to $525 for outpatient hospital services, $475 per stay for observation services, and $45 for outpatient substance abuse sessions, while ambulatory surgical center and blood services have no copay.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 004 IL (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 004 IL (PPO) covers ambulance services with prior authorization, featuring ground ambulance services with no copay to a $350 copay and air ambulance services with a 20% coinsurance. Transportation services to health-related locations are not covered by this plan.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 004 IL (PPO) covers emergency services with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services range from no copay to a $40 copay with no coinsurance, and worldwide emergency services are covered up to $25,000 with copays between $115 and $350 and up to 20% coinsurance.
Primary Care See details
DEVOTED CHOICE GIVEBACK 004 IL (PPO) covers primary care physician services with no copay and no coinsurance, while specialist, therapy, and mental health services require copays ranging from $35 to $50 and no coinsurance. Chiropractic and podiatry services are not covered under these benefits.
Preventive Services See details
DEVOTED CHOICE GIVEBACK 004 IL (PPO) provides partially covered preventive services with no copay and no coinsurance for covered benefits like annual physicals, fitness, and nutritional counseling. However, several sub-services are not covered, including in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, therapeutic massage, caregiver support, telemonitoring, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE GIVEBACK 004 IL (PPO), offering routine exams for a $45 copay and no coinsurance, alongside prescription hearing aids with a copay of $599 to $899 and no coinsurance. However, OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE GIVEBACK 004 IL (PPO), offering one routine eye exam per year with a $0 to $20 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, up to a $200 combined annual limit for contacts, lenses, and frames.
Dental Services See details
Dental services are partially covered by the DEVOTED CHOICE GIVEBACK 004 IL (PPO) plan, with Medicare-covered dental requiring a $45 copay and no coinsurance, and other covered dental services requiring no copay and no coinsurance up to a $250 annual maximum. While many preventive and comprehensive services are covered, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 004 IL (PPO) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Covered Part B chemotherapy and other drugs have no copay and between no coinsurance and 20% coinsurance, while insulin has a $35 copay and between no coinsurance and 20% coinsurance.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 004 IL (PPO) covers Dialysis Services with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 004 IL (PPO) covers durable medical equipment with no copay and 15% coinsurance, and prosthetics or medical supplies with no copay and no coinsurance to 20% coinsurance. Diabetic equipment is partially covered, featuring diabetic supplies with no copay and no coinsurance to 15% coinsurance, but diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 004 IL (PPO) covers diagnostic and radiological services, featuring no copay and no coinsurance for lab services. Diagnostic procedures and tests range from a $0 to $95 copay with no coinsurance, while therapeutic radiological services require a copay and a minimum 20% coinsurance.
Home Health Services See details
DEVOTED CHOICE GIVEBACK 004 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 covered under the DEVOTED CHOICE GIVEBACK 004 IL (PPO) plan with no coinsurance and required prior authorization. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 004 IL (PPO) covers skilled nursing facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by DEVOTED CHOICE GIVEBACK 004 IL (PPO), providing additional preventive services and over-the-counter (OTC) items with no copay and no coinsurance, including a $94 allowance every three months for OTC purchases. Acupuncture and meal benefits are not covered under this plan.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved