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DEVOTED CHOICE GIVEBACK 006 IL (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 006 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 006 IL (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 006 IL (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Metro East. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 006 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 006 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 006 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 006 IL (PPO) plan features an annual prescription drug deductible of $605. For Tier 1 preferred generic drugs, you will pay no copay for one-month, two-month, or three-month supplies at standard pharmacies and through standard mail order. Tier 2 generic drugs are also highly affordable, with standard pharmacy and mail-order copays starting at just $3 for a one-month supply. For brand-name and specialty medications, 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 both standard pharmacy and mail-order fills. Tier 5 specialty drugs also carry a 25% coinsurance for a one-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 006 IL (PPO) plan offers coverage with no copay and no coinsurance for primary care visits, preventive services, home health, and cardiac rehabilitation. For inpatient hospital stays, members pay a daily copay of $475 for days 1 through 4 and no copay for days 5 through 90, with no coinsurance required. Outpatient services and emergency visits are also covered with no coinsurance, featuring a $115 copay for emergency room visits and specialist visits requiring a $45 copay. This plan also provides dental, vision, and hearing benefits, featuring no copay for routine dental services up to a $250 annual maximum and no copay for eyewear up to a $200 annual limit. Hearing exams carry a $45 copay, while skilled nursing facility stays require no copay for the first 20 days followed by a $218 daily copay. Additionally, members receive up to a $100 allowance every three months for over-the-counter items with no copay.
Inpatient Hospital See details
Inpatient hospital services are partially covered by DEVOTED CHOICE GIVEBACK 006 IL (PPO) with no coinsurance, requiring a $475 copay per day for days 1 through 4 and no copay for days 5 through 90. While additional acute stay days are unlimited, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 006 IL (PPO) covers outpatient services with no coinsurance, though prior authorization is required. There is no copay for ambulatory surgical center and blood services, a $45 copay for outpatient substance abuse sessions, and copays ranging from $0 to $475 for outpatient hospital and observation services.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 006 IL (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to access this covered benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 006 IL (PPO) provides partial coverage for Ambulance and Transportation Services, as transportation to health-related locations is not covered. Prior-authorized ground ambulance services require a copay of up to $350.00 and coinsurance, while air ambulance services require 20% coinsurance and a copay.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 006 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 a copay ranging from no copay to $40 with no coinsurance, while worldwide emergency services are covered up to a $25,000 lifetime maximum with a $115 copay for emergency or urgent care and a $350 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 006 IL (PPO) offers primary care provider visits with no copay and no coinsurance, while specialist visits require a $45 copay and no coinsurance. Covered therapeutic and mental health services have copays ranging from $35 to $50 with no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
DEVOTED CHOICE GIVEBACK 006 IL (PPO) offers preventive services with no copay and no coinsurance for covered benefits like annual physical exams and kidney disease education. However, this benefit is only partially covered, excluding in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, post-discharge medication reconciliation, therapeutic massage, adult day health, home-based palliative care, and in-home support services.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE GIVEBACK 006 IL (PPO), featuring hearing exams with a $45.00 copay and no coinsurance, and up to two prescription hearing aids per year with a $599.00 to $899.00 copay and no coinsurance. There is no deductible for these services, but OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
DEVOTED CHOICE GIVEBACK 006 IL (PPO) partially covers vision services, including one annual routine eye exam with a $0 to $20 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a combined annual maximum benefit of $200 for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED CHOICE GIVEBACK 006 IL (PPO) partially covers dental services, offering Medicare-covered dental care for a $45 copay and no coinsurance, and other covered dental services with no copay and no coinsurance up to a $250 annual maximum. Most preventive and comprehensive services are covered, but maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED CHOICE GIVEBACK 006 IL (PPO) with no copay, subject to prior authorization. Under this benefit, 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 under the DEVOTED CHOICE GIVEBACK 006 IL (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED CHOICE GIVEBACK 006 IL (PPO) with no copays, featuring a 19% coinsurance for durable medical equipment (DME) and ranging from no coinsurance to 20% coinsurance for medical supplies, prosthetics, and diabetic supplies. Prior authorization is required, and diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CHOICE GIVEBACK 006 IL (PPO), with prior authorization required for all services. Diagnostic procedures have a $0 to $95 copay and no coinsurance, lab and diagnostic radiological services feature no copay and no coinsurance, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
The DEVOTED CHOICE GIVEBACK 006 IL (PPO) plan 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 by DEVOTED CHOICE GIVEBACK 006 IL (PPO) with no copay and no coinsurance, though prior authorization is required. While some services are covered, standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 006 IL (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but allowing admission without a prior three-day inpatient hospital stay. You will pay no copay for days 1 through 20 and a daily copay of $218 for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 006 IL (PPO) partially covers other services, offering over-the-counter (OTC) items with a $100 limit every three months and additional preventive services with no copay and no coinsurance. Acupuncture and meal benefits are not covered under this plan.
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