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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 Memphis. 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 $147.70. 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 $590.00. After the deductible, you will pay for your prescriptions based on the drug tier and pharmacy you use. For a 30-day supply at a standard pharmacy, you will pay a $10 copay for preferred generic drugs, and 25% coinsurance for standard generic, preferred brand, and non-preferred drugs. The plan has no costs for the catastrophic coverage phase, after your yearly out-of-pocket drug costs reach $2000.00.
Additional Benefits
The Devoted CHOICE GIVEBACK Tennessee (PPO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services, and coverage for ambulance and emergency services. This plan also covers primary care, preventive services, hearing, vision, and dental services, with varying copays and coinsurance amounts depending on the service. Additional benefits include home infusion, dialysis, medical equipment, diagnostic and radiological services, home health, and skilled nursing facility care, often with no copay or a coinsurance. However, the plan does not cover certain services such as acupuncture, over-the-counter items, and specific types of care like private duty nursing and certain home-based services.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with a $425 copay for days 1-4 and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered, while Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $525, Observation Services with a $475 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a $45 copay for both Individual and Group Sessions, and Outpatient Blood Services with three pints deductible waived. 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
Ambulance and Transportation Services are covered by the Devoted CHOICE GIVEBACK Tennessee (PPO) plan. Ground ambulance services have a copay between $0 and $350, and air ambulance services have a 20% coinsurance, while transportation services to a 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, Urgently Needed Services have a copay between $0-$45, and Worldwide Emergency Transportation has a $350 copay and 20% coinsurance.
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 services with a $50 copay. Mental health and psychiatric services have a $45 copay for individual and group sessions, and other health care professional services have a copay between $0 and $50. Additional telehealth benefits are also available with a copay between $0 and $50, 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 annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, 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 include coverage for hearing exams with a $50 copay, fitting/evaluation for hearing aids, and prescription hearing aids, with a copay between $599 and $899 for all types, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. Routine hearing exams are covered for one visit every year.
Vision Services See details
Vision services include eye exams with a $20 copay, and eyewear with a combined maximum plan benefit of $250 every year for both in-network and out-of-network services. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The Devoted CHOICE GIVEBACK Tennessee (PPO) plan covers dental services, including Medicare dental services with a $50 copay, and other dental services with a maximum benefit of $250 per year. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered by this plan.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Insulin, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. 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, the coinsurance ranges from 0% to 20%.
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 with a 20% coinsurance and no copay, prosthetic devices with a 0-20% coinsurance and no copay, and medical supplies with 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, and Lab Services have no copay. Diagnostic Radiological Services have a copay of up to $300, while Therapeutic Radiological Services have a coinsurance of at least 20%. 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, but prior authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, are covered. There is a copay for some services, but the specific copay is not listed.
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 stays for SNF are not covered.
Other Services See details
The Devoted CHOICE GIVEBACK Tennessee (PPO) plan does not cover acupuncture, over-the-counter 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, or Self-Directed Personal Assistance Services. The plan does cover Other 2 services and Other Services, including $0 preventive services, with no maximum plan benefit coverage amount.
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