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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 Nashville. 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 a deductible of $590. After the deductible, you will pay for your drugs in the initial coverage phase. In the initial coverage phase, you will pay a $10 copay for preferred generic drugs at standard or mail order pharmacies. You will pay 25% coinsurance for standard generic, preferred brand, and non-preferred drugs, regardless of the pharmacy. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for your Part D covered drugs.
Additional Benefits
The Devoted CHOICE GIVEBACK Tennessee (PPO) plan offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays. You'll find no copay for primary care physician visits, and services like hearing exams, vision exams, and dental services have copays. The plan also covers ambulance services, emergency services, and home health services, with specific copays or coinsurance amounts depending on the service. This plan includes additional benefits like hearing aids, eyewear, and dental services with annual maximums. Diagnostic and radiological services are covered with copays or coinsurance, and home infusion services are available with copays and coinsurance. However, it's important to note that certain services such as cardiac rehabilitation, additional home health care, and specific dental and vision procedures are not covered.
Inpatient Hospital See details
Inpatient Hospital coverage, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, requires prior authorization. For Inpatient Hospital-Acute, you will pay a $475 copay for days 1-4, and no copay for days 5-90; for Inpatient Hospital Psychiatric, you will pay a $475 copay for days 1-4, and no copay for days 5-90.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services with a copay between $0 and $575, observation services with a $475 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a copay of $45 for both individual and group sessions, and outpatient blood services. Prior authorization is required for some services.
Partial Hospitalization See details
Partial Hospitalization is covered with a $70 copay. Prior authorization is required.
Ambulance and Transportation Services See details
The Devoted CHOICE GIVEBACK Tennessee (PPO) plan covers ambulance services, with a copay of $0-$350 for ground ambulance services and a 20% coinsurance for air ambulance services. 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 copay between $0 and $45. Worldwide Emergency Services have a $110 copay for Worldwide Emergency Coverage and Worldwide Urgent Coverage, and a $350 copay with 20% coinsurance for Worldwide Emergency Transportation.
Primary Care See details
The Devoted CHOICE GIVEBACK Tennessee (PPO) plan covers Primary Care Physician Services with no copay, Chiropractic Services with a $15 copay, Occupational Therapy Services with a $35 copay, Physician Specialist Services with a $50 copay, Mental Health Specialty Services with a $45 copay for individual and group sessions, Other Health Care Professional services with a copay between $0 and $50, Psychiatric Services with a $45 copay for individual and group sessions, Physical Therapy and Speech-Language Pathology Services with a $50 copay, Additional Telehealth Benefits with a copay between $0 and $50, and Opioid Treatment Program Services with a $45 copay. However, Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The Devoted CHOICE GIVEBACK Tennessee (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 and modifications, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. However, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, readmission 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 services include hearing exams with a $50 copay. Routine hearing exams are covered once per year, and fitting/evaluation for hearing aids is covered. Prescription hearing aids (all types) are covered with a copay between $599 and $899 for 2 hearing aids per year, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $50 copay, and eyewear with a combined maximum benefit of $250 every year, including 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 includes coverage for Medicare Dental Services with a $50 copay, and other dental services with a $250 annual maximum. 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 are covered. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Devoted CHOICE GIVEBACK Tennessee (PPO) plan, including Medicare Part B Insulin Drugs with a $35 copay and 20% coinsurance, and other Medicare Part B drugs with 0-20% coinsurance. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE GIVEBACK Tennessee (PPO) plan. The coinsurance for dialysis services is between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and no copay, and Prosthetic Devices with a 0-20% coinsurance and no copay. Medical Supplies have a 20% coinsurance and no copay. Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
The Devoted CHOICE GIVEBACK Tennessee (PPO) plan covers diagnostic and radiological services. Diagnostic Procedures/Tests have a copay between $0 and $95, Lab Services have no copay, Diagnostic Radiological Services have a copay up to $300, and Outpatient X-Ray Services have no copay. Therapeutic Radiological Services have 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK Tennessee (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted CHOICE GIVEBACK Tennessee (PPO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE GIVEBACK Tennessee (PPO) plan, but require prior authorization. For days 1-20 and 61-100, there is no copay, while days 21-60 have a $214 copay. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services include coverage for Other 2 services, but acupuncture, over-the-counter (OTC) items, meal benefits, Dual Eligible SNPs with Highly Integrated Services, 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. $0 Preventive Services are covered.
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