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Devoted CHOICE GIVEBACK Tennessee (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE GIVEBACK Tennessee (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 Tennessee (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE GIVEBACK Tennessee (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Chattanooga and Knoxville. The overall rating for this plan is not yet available for 2025.
It's important to know that Devoted CHOICE GIVEBACK Tennessee (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 Tennessee (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 Tennessee (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 $172.70. 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 $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 Tennessee (PPO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590.00. After the deductible, you will pay a $5 copay for preferred generic drugs at a standard or mail-order pharmacy. Standard generic, preferred brand, and non-preferred drugs have a 25% coinsurance. Once your yearly out-of-pocket drug costs reach $2000, you pay nothing for covered drugs.
Additional Benefits
The Devoted CHOICE GIVEBACK Tennessee (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, and outpatient services have copays depending on the service. The plan also covers primary care, preventive, vision, dental, and hearing services, with specific copays for each. Additional benefits include ambulance services, emergency services, home health services, and skilled nursing facility stays. Medical equipment, diagnostic services, and home infusion are covered with coinsurance or copays. However, some services like acupuncture, over-the-counter items, and certain dental or vision services are not covered.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with a $375 copay for days 1-4, and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient Hospital Services have a copay of $0-$475, Observation Services have a $475 copay, and Individual and Group Sessions for Outpatient Substance Abuse have a copay of $45.00. Ambulatory Surgical Center Services have no copay. Outpatient Blood Services include a three-pint deductible waiver.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE GIVEBACK Tennessee (PPO) plan and requires prior authorization. You will have a $70 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE GIVEBACK Tennessee (PPO) plan, with prior authorization required for all ambulance services. Ground ambulance services have a copay between $0 and $350, and air ambulance services have a 20% coinsurance, while 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 by the Devoted CHOICE GIVEBACK Tennessee (PPO) plan. Emergency Services have a $110 copay, while Urgently Needed Services have a $0-$45 copay. Worldwide Emergency Services has a $110 copay for Worldwide Emergency Coverage and Worldwide Urgent Coverage, and a $350 copay and 20% coinsurance for Worldwide Emergency Transportation.
Primary Care See details
The Devoted CHOICE GIVEBACK Tennessee (PPO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, physician specialist services with a $50 copay, and physical therapy and speech-language pathology services with a $50 copay. Mental health and psychiatric services have a $45 copay for individual and group sessions. Other health care professional services have a copay between $0 and $50. Additional telehealth benefits are covered with a copay between $0 and $50. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive services, including health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, and home and bathroom safety devices and modifications, are covered. 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 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, and counseling services are not covered.
Hearing Services See details
Hearing exams are covered by the Devoted CHOICE GIVEBACK Tennessee (PPO) plan with a $50 copay. Prescription hearing aids are covered, with a copay between $599 and $899 for all types of prescription hearing aids, but hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a $20 copay, eyewear with a combined maximum of $250 every year, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Routine eye exams are covered once per year.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $50 copay, and other dental services with a $250 maximum per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventative 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, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. The plan has a $35 copay and 20% coinsurance for Medicare Part B Insulin Drugs, and a coinsurance between 0% and 20% for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE GIVEBACK Tennessee (PPO) plan. The coinsurance for Dialysis Services is 20%.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment (DME) with 18% coinsurance, Prosthetic Devices with 0-20% coinsurance, and Medical Supplies with 20% coinsurance, but does not cover DME for use outside the home, Diabetic Supplies, or Diabetic Therapeutic Shoes/Inserts.
Diagnostic and Radiological Services See details
The Devoted CHOICE GIVEBACK Tennessee (PPO) plan covers diagnostic and radiological services, including diagnostic procedures/tests with a copay between $0 and $95, and lab services with no copay. Therapeutic Radiological Services have a coinsurance of at most 20%, while outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK Tennessee (PPO) plan, with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. 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 Tennessee (PPO) plan. For days 1-20 and 61-100, there is no copay, and for days 21-60, the copay is $180.
Other Services See details
The Devoted CHOICE GIVEBACK Tennessee (PPO) plan does not cover 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, or Self-Directed Personal Assistance Services. The plan covers Other 2 services, which includes $0 Preventive Services.
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