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DEVOTED CHOICE 001 NC (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE 001 NC (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED CHOICE 001 NC (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE 001 NC (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 2026.
It's important to know that DEVOTED CHOICE 001 NC (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 001 NC (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 001 NC (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 $370.00 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 $6900.00 (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 $6900.00 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 001 NC (PPO) Medicare plan features an annual drug deductible of $370. Under this plan, you will pay no copay for Tier 1 preferred generic and Tier 2 generic drugs filled at standard pharmacies or through standard mail order. This provides excellent savings on common medications for 1-month, 2-month, or 3-month supplies. For higher-tier prescriptions, cost-sharing is based on coinsurance through standard pharmacies and standard mail order. Tier 3 preferred brand drugs require a 19% coinsurance, and Tier 4 non-preferred drugs have a 25% coinsurance. Specialty drugs in Tier 5 are covered with a 28% coinsurance for a 1-month supply.
Additional Benefits
The Devoted Choice 001 NC (PPO) plan offers comprehensive coverage with no copay for primary care visits, preventive services, and home health care. Specialist visits require a $30 copay, and inpatient hospital stays feature a $325 daily copay for the first six days with no copay for days seven through ninety. Emergency room visits carry a $130 copay, which is waived upon admission, while urgent care visits range from no copay to a $45 copay. For extra health needs, the plan provides dental coverage up to a $3,000 annual maximum with no copay for preventive dental services. Vision benefits include a $300 annual eyewear allowance, and routine hearing exams are available for a $30 copay. Additionally, diagnostic lab services and outpatient X-rays require no copay, while durable medical equipment carries a 20% coinsurance.
Inpatient Hospital See details
DEVOTED CHOICE 001 NC (PPO) covers inpatient hospital services with no coinsurance and a copay of $325 per day for days 1 through 6, and no copay for days 7 through 90. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE 001 NC (PPO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital copays range from no copay to $425, observation services carry a $325 copay per stay, and outpatient substance abuse sessions cost a $30 copay.
Partial Hospitalization See details
DEVOTED CHOICE 001 NC (PPO) covers partial hospitalization services with a $60 copay and no coinsurance, although prior authorization is required.
Ambulance and Transportation Services See details
DEVOTED CHOICE 001 NC (PPO) covers ambulance services with prior authorization, offering ground transport with no coinsurance and a copay ranging from no copay to $325, and air transport with a 20% coinsurance and no copay. While some transportation services are covered, trips to plan-approved or any health-related locations are not covered.
Emergency Services See details
DEVOTED CHOICE 001 NC (PPO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no copay to a $45 copay and no coinsurance, while worldwide emergency services are covered up to a $25,000 maximum with varying copays and up to 20% coinsurance for transportation.
Primary Care See details
DEVOTED CHOICE 001 NC (PPO) offers primary care physician services with no copay and no coinsurance, and specialist visits for a $30 copay and no coinsurance. Physical and occupational therapies require a $30 to $50 copay and no coinsurance, podiatry is not covered, and while some chiropractic services are covered, routine and other chiropractic services are not covered.
Preventive Services See details
DEVOTED CHOICE 001 NC (PPO) covers preventive services, including annual physical exams, kidney disease education, and diabetes self-management training, with no copay and no coinsurance. Additional preventive benefits are partially covered with no copay or coinsurance for fitness, nutrition, and alternative therapies, while services such as in-home support, counseling, and personal emergency response systems are not covered.
Hearing Services See details
Hearing services are partially covered under the DEVOTED CHOICE 001 NC (PPO) plan, which features routine hearing exams for a $30 copay and no coinsurance. Covered prescription hearing aids are limited to two per year with copays ranging from $399 to $699 and no coinsurance, but OTC hearing aids and inner ear, outer ear, and over-the-ear prescription aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE 001 NC (PPO), offering one routine eye exam per year with a $0 to $30 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $300 annual maximum for contacts, lenses, frames, and upgrades.
Dental Services See details
DEVOTED CHOICE 001 NC (PPO) dental services are partially covered up to a $3,000 annual maximum for both in- and out-of-network care, with no copay and no coinsurance for preventive services. Medicare-covered dental services require a $30 copay and no coinsurance, restorative and endodontic services have no copay and a 0% to 50% coinsurance, while implant services, orthodontics, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE 001 NC (PPO) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and insulin, require no coinsurance to 20% coinsurance, with insulin drugs also carrying a $35 copay.
Dialysis Services See details
DEVOTED CHOICE 001 NC (PPO) covers Dialysis Services with no copay and a 20% coinsurance, subject to prior authorization requirements.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED CHOICE 001 NC (PPO) with no copays and prior authorization required, as diabetic therapeutic shoes and inserts are not covered. Covered durable medical equipment (DME) has a 20% coinsurance, while prosthetic devices, medical supplies, and diabetic supplies require no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the DEVOTED CHOICE 001 NC (PPO) plan, with no copay for lab services and outpatient X-rays. Diagnostic procedures and tests have a copay of $0 to $95 with no coinsurance, while therapeutic radiological services require a 20% coinsurance, and prior authorization is required for these services.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE 001 NC (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are partially covered by DEVOTED CHOICE 001 NC (PPO) with no coinsurance, requiring prior authorization and copayments for covered services. However, cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE 001 NC (PPO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the Medicare limit are not covered. Prior authorization is required for these services, but a prior three-day inpatient hospital stay is not.
Other Services See details
Other services are partially covered under the DEVOTED CHOICE 001 NC (PPO) plan, which excludes acupuncture and meal benefits. Covered benefits, including additional preventive services and up to $50 every three months for over-the-counter (OTC) items, are available with no copay and no coinsurance.
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