A non-government entity
DEVOTED CHOICE GIVEBACK 012 TN (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 012 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 012 TN (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 012 TN (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Memphis. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 012 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 012 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 012 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:
Sign up for DEVOTED CHOICE GIVEBACK 012 TN (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The DEVOTED CHOICE GIVEBACK 012 TN (PPO) Medicare plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs are highly accessible with no copay for one-, two-, or three-month supplies through standard pharmacies and standard mail order. For Tier 2 generic medications, standard pharmacy copays range from $3.00 to $9.00, while standard mail order offers a slightly lower $7.50 copay for a three-month supply. Higher-tier medications are subject to coinsurance rather than flat copayments. Tier 3 preferred brand drugs require a 21% coinsurance for all supply lengths through standard pharmacies and standard mail order. Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance, with specialty prescriptions limited to a one-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 012 TN (PPO) plan offers robust coverage for core medical needs, featuring no copay or coinsurance for primary care visits, home health care, and standard preventive services. For specialized medical care, patients pay a $50 copay for specialist visits and a $115 copay for emergency room services. If you require hospital care, inpatient stays carry a $475 daily copay for the first four days, with no copay required for days five through ninety. This plan also provides valuable supplemental benefits, including routine dental and eyewear coverage with no copay up to set annual limits, plus a $116 quarterly allowance for over-the-counter items. Routine hearing exams require a $50 copay, while prescription hearing aids have copays ranging from $599 to $899. For specialized treatments like dialysis and certain Part B drugs, you should expect to pay a 20% coinsurance.
Inpatient Hospital See details
Inpatient hospital services are partially covered by DEVOTED CHOICE GIVEBACK 012 TN (PPO) with no coinsurance, though prior authorization is required. For both acute and psychiatric stays, you pay a $475 daily copay for days 1 through 4 and no copay for days 5 through 90, but upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 012 TN (PPO) covers outpatient services with no coinsurance, including ambulatory surgical center and blood services with no copay. Outpatient hospital services require a copay ranging from $0 to $475, observation services carry a $475 copay per stay, and outpatient substance abuse sessions have a $50 copay, with prior authorization required for most services.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 012 TN (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by DEVOTED CHOICE GIVEBACK 012 TN (PPO), with ground ambulance requiring no copay to a $350 copay and no coinsurance, and air ambulance requiring a 20% coinsurance and no copay, both requiring prior authorization. For transportation, some services are covered, but transportation to plan-approved locations and any health-related locations is not covered.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 012 TN (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no copay to a $40 copay with no coinsurance, and worldwide emergency services are covered up to a $25,000 limit with copays up to $350 and a 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 012 TN (PPO) covers primary care physician services with no copay and no coinsurance, while specialist, physical therapy, and mental health services require a $50 copay and no coinsurance. Occupational therapy is covered with a $35 copay and no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are covered by DEVOTED CHOICE GIVEBACK 012 TN (PPO) with no copay and no coinsurance for annual physical exams, kidney disease education, and various screenings. Additional preventive benefits are partially covered with no copay and no coinsurance, but do not cover in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
Hearing Services offered by DEVOTED CHOICE GIVEBACK 012 TN (PPO) are partially covered, featuring a $50 copay and no coinsurance for routine exams and fittings. Prescription hearing aids have no coinsurance and a copay between $599 and $899 for up to two aids per year, but 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 GIVEBACK 012 TN (PPO) offers partially covered vision services, which include one routine eye exam per year for a $0 to $20 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and a $200 annual maximum limit for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED CHOICE GIVEBACK 012 TN (PPO) partially covers dental services, offering Medicare-covered dental with a $50 copay and no coinsurance, and other dental services with no copay and no coinsurance up to a $250 annual maximum. While many diagnostic, preventive, and restorative services are covered, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 012 TN (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry a 0% to 20% coinsurance, while Part B insulin drugs require a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CHOICE GIVEBACK 012 TN (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 012 TN (PPO) partially covers medical equipment with no copays, requiring prior authorization and coinsurance ranging from no coinsurance up to 20% depending on the item. Covered equipment includes durable medical equipment, prosthetics, and diabetic supplies, though diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 012 TN (PPO) covers diagnostic and radiological services, featuring no copay or coinsurance for lab services, and a $0 to $95 copay with no coinsurance for diagnostic procedures. Outpatient X-rays have no copay but require coinsurance, diagnostic radiological services have a $0 minimum copay, and therapeutic radiological services require a copay and a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the DEVOTED CHOICE GIVEBACK 012 TN (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE GIVEBACK 012 TN (PPO) does not cover Cardiac Rehabilitation Services in practice, as all primary sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are listed as not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by DEVOTED CHOICE GIVEBACK 012 TN (PPO) 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 3-day inpatient hospital stay is not required, and additional days beyond the standard 100-day benefit period are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 012 TN (PPO) partially covers other services with no copay and no coinsurance for additional preventive services and over-the-counter (OTC) items up to $116 every three months, while acupuncture and meal benefits are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved