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DEVOTED CHOICE 010 TN (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE 010 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 010 TN (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE 010 TN (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Tri-Cities. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that DEVOTED CHOICE 010 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 010 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 010 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.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 $375.00 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 010 TN (PPO) Medicare plan features an annual prescription drug deductible of $375. For Tier 1 preferred generic drugs, members pay no copay for one-, two-, or three-month supplies at standard pharmacies and through standard mail order. Tier 2 generic drugs require a low copay starting at $5 for a one-month supply, with standard mail-order copays reduced to $12.50 for a three-month supply. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require 24% coinsurance, and Tier 4 non-preferred drugs carry a 25% coinsurance for standard pharmacy and mail-order fills. Tier 5 specialty drugs are limited to a one-month supply and require a 28% coinsurance.
Additional Benefits
The DEVOTED CHOICE 010 TN (PPO) Medicare plan offers comprehensive coverage for core medical services, featuring no copay or coinsurance for primary care visits and home health services. Specialist visits require a $40 copay, while inpatient hospital stays have a $295 daily copay for the first five days and no copay for days six through ninety. Emergency room visits carry a $130 copay, which is waived if you are admitted, and ground ambulance services range from no copay up to a $300 copay. This plan also includes valuable supplemental benefits, such as dental coverage up to a $3,500 annual limit with no copay for preventive care and 0% to 50% coinsurance for restorative services. Vision benefits feature a $350 annual allowance for eyewear with no copay, while hearing exams require a $40 copay and prescription hearing aids range from a $399 to $699 copay. Additionally, members receive a $100 over-the-counter allowance every three months with no copay to help cover everyday health and wellness essentials.
Inpatient Hospital See details
Inpatient Hospital services under DEVOTED CHOICE 010 TN (PPO) are partially covered with no coinsurance, requiring a $295 daily copay for days 1 through 5 and no copay for days 6 through 90 per stay. While unlimited additional acute hospital days are covered, non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE 010 TN (PPO) covers outpatient services with no coinsurance, featuring a $0 to $395 copay for outpatient hospital services and a $295 copay per stay for observation services. There is no copay or coinsurance for ambulatory surgical center and blood services, while outpatient substance abuse sessions require a $40 copay and no coinsurance.
Partial Hospitalization See details
DEVOTED CHOICE 010 TN (PPO) covers partial hospitalization services with an $85.00 copay and no coinsurance. Prior authorization is required before receiving these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by DEVOTED CHOICE 010 TN (PPO), though prior authorization is required for all ambulance services. Ground ambulance services require a copay of no copay to $300 with no coinsurance, air ambulance services carry a 20% coinsurance with no copay, and routine transportation services are not covered.
Emergency Services See details
DEVOTED CHOICE 010 TN (PPO) covers emergency services with a $130 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 $45 copay with no coinsurance, while worldwide emergency services are covered up to a $25,000 maximum, featuring a $130 copay for emergency/urgent care and a $300 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE 010 TN (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $40 copay and no coinsurance. Physical, occupational, and speech therapy services have a $40 to $50 copay and no coinsurance, but podiatry and routine chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by DEVOTED CHOICE 010 TN (PPO) with no copay and no coinsurance for annual physicals, kidney disease education, fitness benefits, and nutritional counseling. Several additional preventive services are not covered, including in-home safety assessments, personal emergency response systems, therapeutic massage, and counseling services.
Hearing Services See details
DEVOTED CHOICE 010 TN (PPO) offers partially covered hearing services, which include hearing exams for a $40 copay and no coinsurance, and up to two prescription hearing aids per year with a copay ranging from $399 to $699 and no coinsurance. Over-the-counter (OTC) hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
DEVOTED CHOICE 010 TN (PPO) provides partially covered vision services, featuring one routine eye exam per year with a $0 to $40 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, offering a combined maximum benefit of $350 per year for contacts, eyeglasses, lenses, frames, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE 010 TN (PPO) up to a $3,500 annual limit for both in- and out-of-network care, excluding maxillofacial prosthetics, implant services, and orthodontics. Medicare-covered dental requires a $40 copay and no coinsurance, while other covered services range from no copay and no coinsurance for preventive care to no copay and 0% to 50% coinsurance for restorative, endodontics, and prosthodontics.
Home Infusion bundled Services See details
DEVOTED CHOICE 010 TN (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs have no copay and a coinsurance ranging from no coinsurance to 20%, while covered Medicare Part B insulin has a $35 copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CHOICE 010 TN (PPO) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Medical Equipment is covered by DEVOTED CHOICE 010 TN (PPO) with no copays, though prior authorization is required. Coinsurance ranges from 20% to 50% for durable medical equipment, no coinsurance to 20% coinsurance for prosthetics and medical supplies, and no coinsurance to 50% coinsurance for diabetic supplies. This benefit is partially covered because diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CHOICE 010 TN (PPO) with prior authorization required. Diagnostic services feature no coinsurance, with no copay for lab work and a $0 to $95 copay for procedures, while radiological services require a minimum 20% coinsurance with a copay for therapeutic services, copays starting at $0 for diagnostic radiology, and no copay for X-rays.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE 010 TN (PPO) plan with no copay and no coinsurance. Prior authorization is required to access this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are provided with no coinsurance under DEVOTED CHOICE 010 TN (PPO), though prior authorization is required. While some services are covered, cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and carry copays ranging from $25 to $40.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE 010 TN (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the Medicare-covered 100 days are not covered.
Other Services See details
DEVOTED CHOICE 010 TN (PPO) partially covers other services with no copay and no coinsurance, which includes additional preventive services and up to $100 every three months for over-the-counter items. Acupuncture and meal benefits are not covered under this plan.
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