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Devoted CHOICE North Carolina (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE North Carolina (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted CHOICE North Carolina (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE North Carolina (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Charlotte. The overall rating for this plan is not yet available for 2025.
It's important to know that Devoted CHOICE North Carolina (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 North Carolina (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 North Carolina (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 $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 $5500.00 (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 $5500.00 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 North Carolina (PPO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590. Once the deductible is met, you will pay a copay or coinsurance for your prescriptions. For preferred generic drugs, you will pay a $5 copay at standard and mail order pharmacies. For standard generic, preferred brand, and non-preferred drugs, you will pay 25% coinsurance at standard and mail order pharmacies. After your yearly out-of-pocket drug costs reach $2000, you pay nothing for covered drugs.
Additional Benefits
The Devoted CHOICE North Carolina (PPO) plan provides coverage for a wide range of services, including inpatient and outpatient hospital care, primary care, and various specialist visits, with copays ranging from $0 to $325. The plan also covers hearing, vision, and dental services, with specific copays and maximum benefits for each. Emergency, ambulance, and home health services are also covered, with some services subject to coinsurance. Additional benefits include coverage for preventive services, home infusion, and medical equipment. However, the plan does not cover certain services like cardiac rehabilitation, acupuncture, and some long-term care options.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For days 1-6, the copay is $325, and for days 7-90, there is no copay; there is no coinsurance. Additional Days for Inpatient Hospital-Acute is covered, but Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay 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 $425, Observation Services with a $325 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a $25 copay for both Individual and Group Sessions, and Outpatient Blood Services. Prior authorization may be required for some services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE North Carolina (PPO) plan with a $60 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE North Carolina (PPO) plan. Ground ambulance services have a copay between $0 and $300, while air ambulance services have a 20% coinsurance; however, transportation services to plan-approved and any health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Devoted CHOICE North Carolina (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a copay between $0 and $45, and Worldwide Emergency Transportation has a $300 copay and 20% coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 copay.
Primary Care See details
The Devoted CHOICE North Carolina (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a copay between $25 and $45, physician specialist services with a $25 copay, and mental health specialty services with a $25 copay for individual and group sessions. The plan also covers other health care professional services with a copay between $0 and $25, psychiatric services with a $25 copay for individual and group sessions, physical therapy and speech-language pathology services with a $25 to $50 copay, additional telehealth benefits with a $0 to $25 copay, and opioid treatment program services with a $25 copay. Routine chiropractic care is not covered, and podiatry services are not covered.
Preventive Services See details
Preventive services, including Medicare-covered services and annual physical exams, are covered. Additional preventive services, such as health education, weight management programs, alternative therapies, fitness benefits, nutritional/dietary benefits, home and bathroom safety devices, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following welcome visits are also covered. 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 exams are covered with a $20 copay, and routine hearing exams are limited to one per year. Prescription hearing aids are covered with a copay between $399 and $699 for all types of hearing aids, but inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services include coverage for eye exams with a $20 copay, eyewear with a combined maximum benefit of $1000 every year, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
Dental Services are covered under the Devoted CHOICE North Carolina (PPO) plan, with a $25 copay for Medicare Dental Services; Other Dental Services have a maximum benefit of $1,000 per year. 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, but 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, the coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Devoted CHOICE North Carolina (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance of 0-20%, Prosthetic Devices with a coinsurance of 0-20%, and Medical Supplies with a 20% coinsurance, but does not cover Durable Medical Equipment for use outside the home, Diabetic Supplies, or Diabetic Therapeutic Shoes/Inserts. The plan also covers Diabetic Equipment, but limits supplies and services to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, lab services with no copay, diagnostic procedures/tests with a copay between $0 and $95, and outpatient X-ray services with no copay. Therapeutic Radiological Services have a coinsurance of at most 20%, and diagnostic radiological services have a copay of at most $300.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE North Carolina (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 North Carolina (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20 and days 61-100, there is no copay, and for days 21-60, the copay is $214. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Devoted CHOICE North Carolina (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, and Self-Directed Personal Assistance Services. The plan does cover Other 2 benefits, including $0 preventive services.
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