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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 Metro East. 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 $142.70. 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 $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 an enhanced alternative drug benefit. The plan has a deductible of $590.00. After the deductible, you'll pay a $10 copay for Tier 1 (Preferred Generic) drugs at standard and mail order pharmacies. For Tier 2 (Standard Generic), Tier 3 (Preferred Brand), and Tier 4 (Non-Preferred Drug) drugs, you'll pay 25% coinsurance at standard and mail order pharmacies. In the Catastrophic Coverage Phase, you pay nothing for covered drugs after your yearly out-of-pocket drug costs reach $2000.00.
Additional Benefits
The Devoted CHOICE GIVEBACK Illinois (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $475 copay for the first four days, with no copay for the rest of the stay, while outpatient services have copays ranging from $0 to $575. This plan also covers primary care with no copay, and offers additional services such as hearing, vision, and dental, each with their own copays and coverage limits. Emergency services have a $110 copay, and ambulance services have a copay from $0-$350, while home health services and skilled nursing facilities are covered with specific copayments.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric, are covered, with a copay of $475 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 are not covered, along with Additional Days for Inpatient Hospital Psychiatric and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric.
Outpatient Services See details
Outpatient Services includes coverage for all outpatient hospital services, with a copay between $0 and $575, and for observation services with a $475 copay. Ambulatory Surgical Center (ASC) Services have no copay, and outpatient substance abuse services, including individual and group sessions, have a copay of $45. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial hospitalization is covered under the Devoted CHOICE GIVEBACK Illinois (PPO) plan. The copay for this benefit is $70.
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 of $0-$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. Emergency Services have a $110 copay, and Urgently Needed Services have a copay between $0 and $45. Worldwide Emergency Transportation has a $350 copay and 20% coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay.
Primary Care See details
The Devoted CHOICE GIVEBACK Illinois (PPO) plan covers primary care services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, and physician specialist services with a $45 copay. Mental health specialty services, psychiatric services, and opioid treatment program services each have a $45 copay for individual and group sessions, while physical therapy and speech-language pathology services have a copay between $45 and $50. Other health care professional services have a copay between $0 and $45. Additional telehealth benefits have a copay between $0 and $45. Podiatry services are not covered.
Preventive Services See details
The Devoted CHOICE GIVEBACK Illinois (PPO) plan covers preventive services including Medicare-covered services, 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 screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG 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, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers, additional sessions of smoking 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 (all types) are covered with a copay between $599 and $899, while prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $45 copay, and coverage for eyewear, with a combined maximum benefit of $250 per year for both in-network and out-of-network services, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
Dental services include a $45 copay for Medicare dental services and a $250 annual maximum for 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 are covered. However, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is 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 by the Devoted CHOICE GIVEBACK Illinois (PPO) plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and no copay, Prosthetic Devices with 0-20% coinsurance and no copay, and Medical Supplies with 20% coinsurance and no copay; however, 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 include coverage for all diagnostic services and radiological services. Diagnostic Procedures/Tests have a minimum copay of $0 and a maximum copay of $95, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $300, and Therapeutic Radiological Services have 20% coinsurance. Outpatient X-Ray Services have 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. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are generally covered, but none of the sub-services are covered by the Devoted CHOICE GIVEBACK Illinois (PPO) plan. There is a copay for some services, but the specific amount is not listed.
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. For days 1-20, there is no copay, and for days 21-100, the copay is $214. 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, and meal benefits, as well as several other services. However, Other 2 services include $0 preventive services.
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