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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 Tri-Cities. 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 $174.70. 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 $590 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy. For preferred generic drugs at a standard pharmacy or through the mail, the copay is $5. Standard generic, preferred brand, and non-preferred drugs have a 25% coinsurance. Once 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 a wide range of benefits, including inpatient and outpatient hospital services, with varying copays. The plan also covers emergency services, primary care, preventive services, and home health services, all with specific cost-sharing requirements. Dental, vision, and hearing services are included, with copays and annual maximums. Additional benefits include coverage for ambulance, partial hospitalization, and skilled nursing facility services, each with its own cost structure. Home infusion, dialysis, and medical equipment are covered, with varying coinsurance percentages. However, the plan does not cover certain services such as acupuncture, OTC items, and specific types of care like private duty nursing and certain types of therapy.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with a copay of $375 for days 1-4, and no copay for days 5-90. Additional Days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, and outpatient substance abuse services, are covered. Outpatient Hospital Services have a copay ranging from $0 to $475, Observation Services have a $375 copay, and Individual and Group Sessions for Outpatient Substance Abuse have a copay of $45. Ambulatory Surgical Center (ASC) Services have no copay, and Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization, with a copay of $70.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a copay between $0 and $350, while air ambulance services have a 20% coinsurance; 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 Coverage and Worldwide Urgent Coverage each have a $110 copay, while Worldwide Emergency Transportation has a $350 copay and 20% coinsurance.
Primary Care See details
Primary Care, including Primary Care Physician Services, is covered. Chiropractic Services have a $15 copay. Occupational Therapy Services have a $35 copay, and Physician Specialist Services have a $45 copay. Mental Health Specialty Services and Psychiatric Services have a $45 copay. Physical Therapy and Speech-Language Pathology Services have a $50 copay. Additional Telehealth Benefits have a copay between $0 and $45, and Opioid Treatment Program Services have a $45 copay. Routine Chiropractic Care is not covered, and Podiatry Services are not covered.
Preventive Services See details
The Devoted CHOICE GIVEBACK Tennessee (PPO) plan covers preventive services, including Medicare-covered services, annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, glaucoma screenings, 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, 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 Services includes coverage for hearing exams with a $50 copay, routine hearing exams (1 per year), and fitting/evaluation for hearing aids. Prescription hearing aids are partially covered, but inner ear, outer ear, and over-the-ear hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $20 copay, and eyewear including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Eyewear has a combined maximum benefit of $250 every year for both in-network and out-of-network services.
Dental Services See details
The Devoted CHOICE GIVEBACK Tennessee (PPO) plan covers dental services, including oral exams with a $45 copay, 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, with a $250 annual maximum. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE GIVEBACK Tennessee (PPO) plan. The plan has a coinsurance of 20% for dialysis services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 19% coinsurance, Prosthetic Devices with 0-20% coinsurance, and Medical Supplies with 20% coinsurance; however, Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services with a copay, Diagnostic Procedures/Tests with a copay between $0 and $95, and Lab Services with no copay. Radiological Services are covered, including Diagnostic Radiological Services with a copay up to $300, Therapeutic Radiological Services with 20% coinsurance, and Outpatient X-Ray Services with no copay.
Home Health Services See details
Home Health Services are covered with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but 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 are not covered. There is a copay for some services, but the exact amount is not specified.
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, and for days 21-60, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Devoted CHOICE GIVEBACK Tennessee (PPO) plan does not cover acupuncture, over-the-counter (OTC) items, or meal benefits. The plan also does not cover 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.
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