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DEVOTED CHOICE GIVEBACK 002 TN (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 002 TN (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 TN (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 002 TN (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Chattanooga and Knoxville. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 002 TN (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 TN (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 TN (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 $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 prescription drug coverage for the DEVOTED CHOICE GIVEBACK 002 TN (PPO) plan features an annual drug deductible of $605. Under this plan, you will pay no copay for Tier 1 preferred generic drugs filled through standard pharmacies or standard mail order. For Tier 2 generic medications, standard pharmacy copays range from $3 to $9, while standard mail order copays range from $3 to $7.50 depending on the supply duration. Higher-tier medications require coinsurance rather than set copays during the initial coverage phase. Tier 3 preferred brand drugs carry a 22% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance for standard pharmacy and mail order services. This plan structure helps you manage costs by offering affordable generic options alongside clear cost-sharing percentages for brand-name and specialty prescriptions.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 002 TN (PPO) plan offers comprehensive medical coverage with predictable out-of-pocket costs, featuring no copay and no coinsurance for primary care visits, preventive services, and home health care. For specialist visits, patients will pay a $50 copay, while inpatient hospital stays require a $475 daily copay for the first four days followed by no copay for days five through 90. Emergency room visits carry a $115 copay, which is waived if admitted, and ground ambulance services require up to a $350 copay with no coinsurance. Supplemental benefits include dental care with no copay for preventive and comprehensive services up to a $250 yearly limit, and vision services featuring an annual routine exam with up to a $50 copay alongside a $200 annual allowance for eyewear with no copay. Hearing services offer a routine annual exam for a $50 copay and partial coverage for prescription hearing aids with copays between $599 and $899. Additionally, members receive an over-the-counter allowance of up to $120 every three months to help cover health-related items at no extra cost.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 002 TN (PPO) covers inpatient hospital services with no coinsurance, requiring a $475 copay per day for days 1 through 4 and no copay for days 5 through 90 for both acute and psychiatric stays. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, though unlimited additional days are covered for acute care.
Outpatient Services See details
Outpatient services under DEVOTED CHOICE GIVEBACK 002 TN (PPO) are covered with no coinsurance, though prior authorization is required for most treatments. Patients will pay no copay for ambulatory surgical center and blood services, a $50 copay for outpatient substance abuse sessions, $475 per stay for observation services, and a copay ranging from $0 to $575 for outpatient hospital services.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 002 TN (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required for this covered benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered under the DEVOTED CHOICE GIVEBACK 002 TN (PPO) plan, as transportation to plan-approved or other health-related locations is not covered. Ground ambulance services require up to a $350 copay and no coinsurance, while air ambulance services require a 20% coinsurance and no copay, with prior authorization required for all ambulance trips.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 002 TN (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with no copay to a $40 copay and no coinsurance. Worldwide emergency services are covered up to a $25,000 lifetime maximum, featuring a $115 copay and no coinsurance for emergency or urgent care, and a $350 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 002 TN (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, and mental health services carry a $50 copay and no coinsurance. Occupational therapy is covered with a $35 copay and no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered under the DEVOTED CHOICE GIVEBACK 002 TN (PPO) plan with no copay and no coinsurance for covered benefits, including annual physicals, fitness benefits, and glaucoma screenings. However, several supplemental preventive services are not covered, such as in-home safety assessments, personal emergency response systems (PERS), therapeutic massage, and in-home support services.
Hearing Services See details
DEVOTED CHOICE GIVEBACK 002 TN (PPO) covers hearing services with no deductible, offering annual routine hearing exams for a $50 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $599 to $899 for up to two devices per year, though inner ear, outer ear, over the ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE GIVEBACK 002 TN (PPO), featuring one annual routine eye exam with a copay ranging from no copay up to $50, no coinsurance, and no deductible, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, providing up to a $200 annual maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED CHOICE GIVEBACK 002 TN (PPO) covers Medicare-covered dental services with a $50 copay and no coinsurance, while other preventive and comprehensive dental services are covered with no copay and no coinsurance up to a $250 yearly limit. This benefit is partially covered, as 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 TN (PPO) with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and radiation, carry no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 002 TN (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 002 TN (PPO) partially covers medical equipment with no copay, but coinsurance ranges from no coinsurance up to 20% for covered durable medical equipment, prosthetics, medical supplies, and diabetic supplies. Prior authorization is required for these services, 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 002 TN (PPO) with prior authorization required. Diagnostic services carry no coinsurance, featuring lab services with no copay and diagnostic procedures with a $0 to $95 copay, while radiological services include outpatient X-rays with no copay and therapeutic services with a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED CHOICE GIVEBACK 002 TN (PPO) with no copay and no coinsurance, although prior authorization is required for these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the DEVOTED CHOICE GIVEBACK 002 TN (PPO) plan with no copay, no coinsurance, and prior authorization required. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered under this plan.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 002 TN (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, no prior three-day hospital stay is needed, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 002 TN (PPO) partially covers other services, offering over-the-counter (OTC) items up to $120 every three months and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and other services under this category are not covered.
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