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Devoted CHOICE GIVEBACK North Carolina (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE GIVEBACK 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 GIVEBACK North Carolina (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE GIVEBACK 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 GIVEBACK 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 GIVEBACK 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 GIVEBACK 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. Additionally, this plan comes with a Part B Premium reduction of $157.70. 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 North Carolina (PPO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590. Once you meet your deductible, you will pay the costs of your drugs based on the tier and pharmacy you use. In the initial coverage phase, you will pay a $5 copay for preferred generic drugs at a standard or mail pharmacy. For standard generic, preferred brand, and non-preferred drugs, you will pay 25% coinsurance. After your yearly out-of-pocket drug costs reach $2000, you pay nothing for covered drugs.
Additional Benefits
The Devoted CHOICE GIVEBACK North Carolina (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient hospital services, with varying copays depending on the service. It also includes coverage for primary care, preventive services, hearing, vision, and dental services. This plan provides additional benefits such as ambulance services, emergency care, and home health services with no copay in some instances, as well as coverage for medical equipment and home infusion. However, some services like cardiac rehabilitation and certain "other services" are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization. For Inpatient Hospital-Acute, you will pay a $340 copay for days 1-5, and no copay for days 6-90, while for Inpatient Hospital Psychiatric, you will also pay a $340 copay for days 1-5, and no copay for days 6-90. Additional Days for Inpatient Hospital-Acute is covered with no copay, while 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 all outpatient hospital services, with a copay ranging from $0 to $440, and observation services with a $440 copay. Ambulatory Surgical Center (ASC) Services have no copay, while Outpatient Substance Abuse services have a $45 copay for both individual and group sessions. Outpatient Blood Services are also covered, including services not usually covered by Medicare plans.
Partial Hospitalization See details
Partial Hospitalization is covered under the Devoted CHOICE GIVEBACK North Carolina (PPO) plan, 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 North Carolina (PPO) plan. Ground ambulance services have a copay between $0 and $350, and air ambulance services have a 20% coinsurance; however, transportation services to any 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 North Carolina (PPO) plan. Emergency Services has a $110 copay, Urgently Needed Services have a copay of $0-$45, and Worldwide Emergency Services has a $110 copay for Worldwide Emergency Coverage and Worldwide Urgent Coverage, and a $350 copay and 20% coinsurance for Worldwide Emergency Transportation.
Primary Care See details
The Devoted CHOICE GIVEBACK North Carolina (PPO) plan covers Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services. Chiropractic services have a $15 copay, Physician Specialist Services have a $45 copay, and Physical Therapy and Speech-Language Pathology Services have a $45-$50 copay.
Preventive Services See details
Preventive Services are covered, including Medicare-covered services and annual physical exams. Additional preventive services include Health Education, Weight Management Programs, Alternative Therapies, Nutritional/Dietary Benefit, Fitness Benefit, Home and Bathroom Safety Devices and Modifications, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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 (including Web/Phone-based technologies and Nursing Hotline), and Counseling Services are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $45 copay, and prescription hearing aids with a copay between $599 and $899. Prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are also not covered.
Vision Services See details
Vision Services include coverage for eye exams with a $20 copay, as well as eyewear with a combined maximum benefit of $250 every year. This plan also covers contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
The Devoted CHOICE GIVEBACK North Carolina (PPO) plan covers Medicare Dental Services with a $45 copay, and also covers other dental services, including oral exams, dental x-rays, and more with no copay. This plan has a $250 maximum benefit per year for in-network and out-of-network services, but does not cover Maxillofacial Prosthetics, Implant Services, or Orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay and 20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Devoted CHOICE GIVEBACK North Carolina (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 15% coinsurance and Prosthetic Devices with 0-20% coinsurance, but Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. Medical Supplies have a 15% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with some services requiring prior authorization. Diagnostic Procedures/Tests have a copay between $0 and $95, and Lab Services have no copay. Diagnostic Radiological Services have a copay up to $300, while Therapeutic Radiological Services have a 20% coinsurance. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK North Carolina (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 not covered by the Devoted CHOICE GIVEBACK North Carolina (PPO) plan. While the plan covers the benefit, the sub-services including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Devoted CHOICE GIVEBACK North Carolina (PPO) plan, but require prior authorization. There is no copay for days 1-20 and days 61-100, but there is a $200 copay for days 21-60. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays are not covered.
Other Services See details
Other Services are not covered by the Devoted CHOICE GIVEBACK North Carolina (PPO) plan, including acupuncture, over-the-counter items, meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing services, case management, institution for mental disease services, services in an intermediate care facility, case management, tobacco cessation counseling, 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. However, Other 2 services are covered, and there is no maximum plan benefit coverage amount.
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