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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 Rockford. 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 depending on the drug tier and pharmacy. For example, standard generic drugs have a $10 copay and preferred brand drugs have 25% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. If you qualify for the low-income subsidy, you will pay $0.00.
Additional Benefits
The Devoted CHOICE GIVEBACK Illinois (PPO) plan offers a range of benefits, including inpatient hospital stays with a $475 copay for the first four days, and no copay for days 5-90. The plan covers outpatient services, primary care, preventive services, hearing, vision, dental, and home health services. Copays vary depending on the service, with some services like outpatient X-rays and lab services having no copay. Additional benefits include coverage for ambulance services with copays varying from $0 to $350 for ground ambulance, and 20% coinsurance for air ambulance. Other services like home infusion, dialysis, medical equipment, diagnostic and radiological services, and skilled nursing facility (SNF) services are also covered. However, services like cardiac rehabilitation and certain "Other Services" are not covered, or have limited coverage.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric, are covered. For acute inpatient hospital stays, you will pay a $475 copay for days 1-4, and no copay for days 5-90; for psychiatric inpatient hospital stays, you will pay a $475 copay for days 1-4, and no copay for days 5-90. Additional days for inpatient hospital psychiatric are not covered, and non-Medicare-covered stays and upgrades for inpatient hospital acute are not covered.
Outpatient Services See details
Outpatient Services, including Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, Outpatient Substance Abuse Services, and Outpatient Blood Services, are covered. Outpatient Hospital Services have a copay between $0 and $575, Observation Services have a $475 copay, Individual and Group Sessions for Outpatient Substance Abuse have a copay of $45, and Ambulatory Surgical Center (ASC) Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered with a $70 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered. Ground ambulance services have a copay between $0 and $350, while air ambulance services have a 20% coinsurance. Transportation services to any health-related location 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, Urgently Needed Services have a copay between $0 and $45, and Worldwide Emergency Transportation has a $350 copay and 20% coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage each have a $110 copay.
Primary Care See details
The Devoted CHOICE GIVEBACK Illinois (PPO) plan covers primary care services, including a $15 copay for chiropractic services, a $35 copay for occupational therapy services, and a $45 copay for physician specialist services. Mental health specialty services, including individual and group sessions, have a $45 copay. Other Health Care Professional services may have a copay from $0 to $45, and psychiatric services, including individual and group sessions, also have a $45 copay. Physical therapy and speech-language pathology services have a copay between $45 and $50, while additional telehealth benefits have a copay ranging from $0 to $45. Opioid Treatment Program Services have a $45 copay.
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 and modifications, kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit. However, in-home safety assessments, personal emergency response systems, medical nutrition therapy, 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 routine hearing exams with a $45 copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a copay between $599 and $899, while hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision services include eye exams with a $45 copay, eyewear with a combined maximum benefit of $250 per year, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Routine eye exams are covered once per year.
Dental Services See details
Dental services include coverage for Medicare dental services with a $45 copay, and other dental services, up to a maximum of $250 per year. Oral exams, dental x-rays, other diagnostic services, prophylaxis (cleaning), fluoride treatment, other preventive services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay and 20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Devoted CHOICE GIVEBACK Illinois (PPO) plan. The plan has a coinsurance of 20% for dialysis services.
Medical Equipment See details
Medical Equipment is covered by the Devoted CHOICE GIVEBACK Illinois (PPO) plan, which includes Durable Medical Equipment (DME) with 20% coinsurance and Prosthetic Devices with 0-20% coinsurance; however, Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered. Medical Supplies have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services includes coverage for all diagnostic services with a copay between $0 and $95, and lab services with no copay. Radiological Services include coverage for diagnostic radiological services with a copay up to $300, therapeutic radiological services with 20% coinsurance, and outpatient X-ray services with no copay.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK Illinois (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services are covered. This means that you will pay the full cost for Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE GIVEBACK Illinois (PPO) plan, but require prior authorization. You will have no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services are not covered, including acupuncture, over-the-counter items, meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services. The plan covers "Other 2" benefits, and $0 preventive services.
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