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DEVOTED CHOICE GIVEBACK 005 TN (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 005 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 005 TN (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 005 TN (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Nashville. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 005 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 005 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 005 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 DEVOTED CHOICE GIVEBACK 005 TN (PPO) prescription drug plan features an annual drug deductible of $605. Beneficiaries will enjoy no copay for Tier 1 preferred generic drugs filled at standard pharmacies or ordered through standard mail delivery. For Tier 2 generic drugs, costs are also low, starting at a $3 copay for a one-month supply. For higher-tier medications, the plan transitions from flat copays to coinsurance. Tier 3 preferred brand drugs require a 22% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs carry a 25% coinsurance. These cost-sharing rates apply to both standard retail pharmacy fills and mail-order prescriptions.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 005 TN (PPO) plan offers affordable healthcare coverage with no copay and no coinsurance for primary care visits, preventive services, and home health care. For specialist visits, members will pay a $50 copay with no coinsurance, while emergency room services require a $115 copay. Inpatient hospital stays have no coinsurance but require a $475 daily copay for the first four days, followed by no copay for days five through ninety. This plan also features essential supplemental benefits, including preventive dental care and select eyewear with no copay up to specified annual limits, alongside routine vision exams ranging from no copay to a $50 copay. Prescription hearing aids require a copay of $599 to $899, while durable medical equipment is covered with a 20% coinsurance. Additionally, members can access an over-the-counter item allowance of up to $105 every three months to help manage everyday health needs.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 005 TN (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $475 daily copay for days 1 through 4 and no copay for days 5 through 90. This benefit is partially covered as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 005 TN (PPO) covers outpatient services with no coinsurance, including no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $575, observation services cost a $475 copay per stay, and outpatient substance abuse sessions have a $50 copay.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 005 TN (PPO) covers partial hospitalization services with a $70 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance services are covered by DEVOTED CHOICE GIVEBACK 005 TN (PPO) with a copay ranging from no copay to $350 for ground transport and a 20% coinsurance for air transport, both requiring prior authorization. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Emergency services under the DEVOTED CHOICE GIVEBACK 005 TN (PPO) are covered with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services range from no copay to a $40 copay with no coinsurance, while worldwide emergency services are covered up to $25,000 with a $115 copay for emergency or urgent care and a $350 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 005 TN (PPO) offers primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, and mental health services require a $50 copay and no coinsurance. Occupational therapy is covered with a $35 copay and no coinsurance, telehealth benefits range from no copay to a $50 copay with no coinsurance, and podiatry is not covered. For chiropractic services, some services are covered with a $15 copay and no coinsurance, but routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services are covered by DEVOTED CHOICE GIVEBACK 005 TN (PPO) with no copay and no coinsurance, including annual physical exams, kidney disease education, and glaucoma screenings. However, this benefit is only partially covered, as sub-services such as in-home safety assessments, personal emergency response systems, medical nutrition therapy, therapeutic massage, adult day health, in-home support, and caregiver support are not covered.
Hearing Services See details
Hearing Services are partially covered under the DEVOTED CHOICE GIVEBACK 005 TN (PPO) plan, with routine exams requiring a $50 copay and no coinsurance, and prescription hearing aids requiring a $599 to $899 copay and no coinsurance. OTC hearing aids, along with inner ear, outer ear, and over the ear prescription hearing aids, are not covered under this plan.
Vision Services See details
DEVOTED CHOICE GIVEBACK 005 TN (PPO) provides partially covered vision services, including one routine eye exam per year with a $0 to $50 copay and no coinsurance, though other eye exam services are not covered. Covered eyewear, including contacts, frames, lenses, and upgrades, has no copay and no coinsurance up to a $200 combined annual maximum.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE GIVEBACK 005 TN (PPO), offering no copay and no coinsurance for most preventive and comprehensive services up to a $250 annual maximum, while Medicare-covered dental requires a $50 copay and no coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 005 TN (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs require 0% to 20% coinsurance, while Part B insulin drugs have a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 005 TN (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 005 TN (PPO) partially covers medical equipment with no copay, though prior authorization is required and coinsurance ranges from no coinsurance to 20%. Durable medical equipment requires a 20% coinsurance, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 005 TN (PPO) covers diagnostic and radiological services with prior authorization required. Diagnostic services feature no coinsurance, with no copay for lab services and a $0 to $95 copay for diagnostic tests, while radiological services have no copay for X-rays and diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE GIVEBACK 005 TN (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE GIVEBACK 005 TN (PPO) does not cover cardiac rehabilitation services in practice. Although the overall benefit is technically listed with no coinsurance, all individual sub-services—including cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD)—are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 005 TN (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and the plan allows for admission without requiring a prior 3-day inpatient hospital stay.
Other Services See details
Other Services under the DEVOTED CHOICE GIVEBACK 005 TN (PPO) are partially covered, offering over-the-counter (OTC) items up to $105 every three months and additional preventive services with no copay and no coinsurance. However, acupuncture, meal benefits, and other additional services are not covered under this plan.
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