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Devoted CHOICE GIVEBACK Washington (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE GIVEBACK Washington (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 Washington (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE GIVEBACK Washington (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Washington. The overall rating for this plan is not yet available for 2025.
It's important to know that Devoted CHOICE GIVEBACK Washington (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 Washington (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 Washington (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 $137.60. 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 $10000.00 (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 $10000.00 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 Washington (PPO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590.00. After the deductible is met, you will pay a $10 copay for preferred generic drugs at standard and mail order pharmacies. For standard generic, preferred brand, and non-preferred drugs, you will pay 25% coinsurance. After your yearly out-of-pocket drug costs reach $2000.00, you pay nothing for Part D covered drugs.
Additional Benefits
The Devoted CHOICE GIVEBACK Washington (PPO) plan offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays depending on the service. It also covers primary care, preventive services, hearing, vision, and dental services, with copays and coinsurance amounts that vary. This plan provides additional benefits like home health services with no copay, and covers services like ambulance, emergency care, and diagnostic services.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $425 copay for days 1-5, and no copay for days 6-90; Inpatient Hospital Psychiatric has a $425 copay for days 1-4, and no copay for days 5-90. Additional Days for Inpatient Hospital-Acute is covered, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days for Inpatient Hospital Psychiatric and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $575, observation services have a $475 copay, and ambulatory surgical center services have no copay. Individual and group sessions for outpatient substance abuse have a copay between $55 and $55. Outpatient blood services include a waived deductible of three pints.
Partial Hospitalization See details
Partial hospitalization is covered by the Devoted CHOICE GIVEBACK Washington (PPO) plan. You will pay a $105 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE GIVEBACK Washington (PPO) plan. 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 for Devoted CHOICE GIVEBACK Washington (PPO) include a $125 copay, and no coinsurance. Urgently Needed Services have a copay between $0 and $55, with no coinsurance. Worldwide Emergency Services include a $125 copay for Worldwide Emergency and Urgent Coverage, while Worldwide Emergency Transportation has a $350 copay and 20% coinsurance.
Primary Care See details
The Devoted CHOICE GIVEBACK Washington (PPO) plan covers Primary Care services, including Primary Care Physician services, Chiropractic Services with a $20 copay, Occupational Therapy Services with a $45 copay, and Physician Specialist Services with a $55 copay. The plan also covers Mental Health Specialty Services, including individual and group sessions, and Psychiatric Services, including individual and group sessions, each with a $55 copay. Additional benefits include Physical Therapy and Speech-Language Pathology Services with a $55 copay, Additional Telehealth Benefits with a copay ranging from $0 to $55, and Opioid Treatment Program Services with a $55 copay. Routine Chiropractic Care is not covered.
Preventive Services See details
The Devoted CHOICE GIVEBACK Washington (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, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit. This plan does not cover in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy (MNT), 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, or counseling services.
Hearing Services See details
Hearing exams are covered with a $55 copay, including routine hearing exams and fitting/evaluation for hearing aids. Prescription hearing aids are covered with a copay between $599 and $899, but inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
The Devoted CHOICE GIVEBACK Washington (PPO) plan covers vision services, including routine eye exams with a $55 copay. Eyewear is covered with a combined maximum benefit of $250 per year for both in-network and out-of-network services, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Devoted CHOICE GIVEBACK Washington (PPO) covers dental services, including 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. Medicare Dental Services require a $55 copay, and the plan does not cover maxillofacial prosthetics, implant services, or orthodontics, and has a $250 annual maximum for other dental services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Devoted CHOICE GIVEBACK Washington (PPO) plan. For Medicare Part B Insulin Drugs, there is a $35 copay and a 20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE GIVEBACK Washington (PPO) plan. The plan has a coinsurance of 20% for dialysis services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with an 18% coinsurance and no copay, Prosthetic Devices with a 0-20% coinsurance and no copay, and Medical Supplies with a 20% coinsurance and no copay, but 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, lab services with no copay, and diagnostic radiological services with a copay of at most $300.00. Therapeutic Radiological Services are covered with a coinsurance of at most 20%, and outpatient X-Ray services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK Washington (PPO) plan with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are generally covered, but the plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services. The cost-sharing information is available below.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE GIVEBACK Washington (PPO) plan, but require prior authorization. For days 1-20, the copay is $10, for days 21-60 the copay is $214, and there is no copay for days 61-100. 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, as 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 are not covered. Other 2 benefits include $0 preventive services.
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