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DEVOTED CHOICE GIVEBACK 002 WA (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 002 WA (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 002 WA (PPO) in 2026, please refer to our full plan details page.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
DEVOTED CHOICE GIVEBACK 002 WA (PPO) is a PPO plan offered by Devoted Health Insurance Company of Washington available for the 2026 plan year to people living in Washington. CMS star rating not available for 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 002 WA (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 002 WA (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 002 WA (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 $155.00. 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 that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6750.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $6750.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $10000.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $10000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
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 002 WA (PPO) plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs have no copay for a 1-month, 2-month, or 3-month supply at standard pharmacies and through standard mail order. For Tier 2 generic medications, you will pay a low copay starting at $3.00 for a 1-month supply, with maximum savings offered on 3-month mail-order refills. For higher-tier prescription drugs, cost-sharing transitions from flat copays to coinsurance. Tier 3 preferred brand drugs require a 21% coinsurance, while Tier 4 non-preferred drugs carry a 25% coinsurance for standard pharmacy and mail-order fills. Tier 5 specialty tier medications also require a 25% coinsurance for a 1-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 002 WA (PPO) plan offers comprehensive medical coverage featuring no copay and no coinsurance for primary care visits, home health services, and routine lab tests or X-rays. Specialist visits, physical therapy, and mental health services require a $55 copay with no coinsurance. For hospital stays, members pay a $475 copay for the first few days of inpatient care and no copay for subsequent days, while outpatient hospital services range from no copay up to a $575 copay. Preventive dental and vision services are highly accessible, featuring no copay for most routine dental care up to a $250 annual limit and up to $200 annually for eyewear. Routine hearing exams carry a $55 copay, while covered prescription hearing aids require a copay between $599 and $899. Emergency care is covered with a $130 copay, which is waived if you are admitted to the hospital within 24 hours.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 002 WA (PPO) partially covers inpatient hospital services with no coinsurance, requiring prior authorization and a $475 copay for days 1 to 5 of acute stays and days 1 to 4 of psychiatric stays, with no copay for subsequent days. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED CHOICE GIVEBACK 002 WA (PPO) with no coinsurance, featuring a $0 to $575 copay for outpatient hospital services and a $475 copay per stay for observation services. Ambulatory surgical center and outpatient blood services have no copay and no coinsurance, while individual and group outpatient substance abuse sessions require a $55 copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by DEVOTED CHOICE GIVEBACK 002 WA (PPO) with a $105 copay and no coinsurance. Prior authorization is required to receive this benefit.
Ambulance and Transportation Services See details
Ambulance services under DEVOTED CHOICE GIVEBACK 002 WA (PPO) are covered with a copay of $0 to $350 for ground transport and a 20% coinsurance for air transport, with prior authorization required. Routine transportation services to health-related locations are not covered.
Emergency Services See details
Emergency services are covered by DEVOTED CHOICE GIVEBACK 002 WA (PPO) with a $130 copay and no coinsurance, with the copay waived if admitted to the hospital within 24 hours. Urgently needed services require no copay to a $50 copay with no coinsurance, and worldwide emergency services are covered up to $25,000 with copays up to $350 and a 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 002 WA (PPO) offers primary care provider services with no copay and no coinsurance, while specialist visits, physical therapy, and mental health services require a $55 copay and no coinsurance. Occupational therapy is covered with a $50 copay and no coinsurance, podiatry is not covered, and chiropractic services are partially covered since routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by DEVOTED CHOICE GIVEBACK 002 WA (PPO) with no copay and no coinsurance for covered benefits like annual physicals, fitness programs, and alternative therapies. However, several sub-services are not covered, including in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, medication reconciliation, re-admission prevention, wigs, adult day health, palliative care, in-home support, caregiver support, tobacco cessation, disease management, telemonitoring, remote access, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE GIVEBACK 002 WA (PPO), with routine exams requiring a $55 copay and no coinsurance, and covered prescription hearing aids requiring a copay between $599 and $899 with no coinsurance. Over-the-counter (OTC) hearing aids, as well as inner ear, outer ear, and over-the-ear prescription hearing aids, are not covered.
Vision Services See details
DEVOTED CHOICE GIVEBACK 002 WA (PPO) offers partially covered vision services, including one routine eye exam per year with a $0 to $55 copay and no coinsurance, but other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance, providing up to a $200 annual maximum benefit for contacts, lenses, frames, and upgrades.
Dental Services See details
Dental services are partially covered by the DEVOTED CHOICE GIVEBACK 002 WA (PPO) plan, which features a $55 copay and no coinsurance for Medicare-covered dental care, and no copay or coinsurance for most preventive and comprehensive services up to a $250 annual limit. 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 002 WA (PPO) with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and insulin, require a coinsurance ranging from no coinsurance up to 20%, with insulin also requiring a $35 copay.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 002 WA (PPO) covers Dialysis Services with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 002 WA (PPO) covers medical equipment with no copays, requiring a 19% coinsurance for durable medical equipment (DME) and ranging from no coinsurance to 20% coinsurance for prosthetics and medical supplies. Diabetic equipment is partially covered with no copay and ranging from no coinsurance to 19% coinsurance for supplies, though diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under DEVOTED CHOICE GIVEBACK 002 WA (PPO) with no coinsurance for diagnostic services, which feature no copay for lab services and a $0 to $95 copay for diagnostic procedures. Diagnostic radiological services start at no copay, outpatient X-rays have no copay, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home health services are covered by DEVOTED CHOICE GIVEBACK 002 WA (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE GIVEBACK 002 WA (PPO) does not cover Cardiac Rehabilitation Services, as none of the individual sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are covered in practice.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 002 WA (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, no prior three-day hospital stay is needed, and additional days beyond the standard Medicare-covered period are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 002 WA (PPO) partially covers other services, offering unlimited acupuncture and additional preventive services not covered by Medicare with no copay and no coinsurance. Over-the-counter (OTC) items and meal benefits are not covered under this plan.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
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