A non-government entity
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 002 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 GIVEBACK 002 NC (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 002 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 GIVEBACK 002 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 GIVEBACK 002 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 GIVEBACK 002 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. 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 002 NC (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 002 NC (PPO) Medicare plan features an annual prescription drug deductible of $605. For initial coverage, Tier 1 preferred generic drugs are highly affordable with no copay required for standard pharmacy or mail-order fills. Tier 2 generic drug copays start at $3.00 for a one-month supply, with minor increases for multi-month supplies. Brand-name and specialty medications under this plan transition to a coinsurance model for standard pharmacy and mail-order services. You will pay a 21% coinsurance for Tier 3 preferred brand drugs. Tier 4 non-preferred drugs and Tier 5 specialty drugs both require a 25% coinsurance.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 002 NC (PPO) plan offers comprehensive coverage with no copays for primary care visits, preventive services, home health care, and routine lab work or X-rays. For specialist visits, Medicare-covered dental, and routine hearing exams, members pay a $45 copay, while inpatient hospital stays require a daily copay of $440 for the first few days followed by no copay. Outpatient hospital services range from no copay up to a $540 copay, and emergency room visits feature a $115 copay, which is waived if you are admitted. Additional benefits include partially covered dental and vision care, featuring no copays for preventive dental up to a $250 annual limit and no copays for routine eyewear up to $200. Skilled nursing facility stays have no copay for the first 20 days, while durable medical equipment and dialysis services generally require a 20% coinsurance. Members also receive an over-the-counter allowance of up to $116 every three months with no copay, helping to reduce everyday out-of-pocket health costs.
Inpatient Hospital See details
Inpatient hospital services are partially covered by DEVOTED CHOICE GIVEBACK 002 NC (PPO) with no coinsurance, requiring a daily copay of $440 for days 1 to 5 for acute stays and days 1 to 4 for psychiatric stays, followed by no copay for subsequent days up to day 90. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered under this plan.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 002 NC (PPO) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and blood services. Outpatient hospital services require a copay of $0 to $540, observation services have a $440 copay per stay, and outpatient substance abuse sessions carry a $45 copay.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 002 NC (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 002 NC (PPO) covers ambulance services with prior authorization, featuring a copay ranging from no copay to $350 with no coinsurance for ground ambulance, and a 20% coinsurance with no copay for air ambulance. Transportation services to plan-approved or health-related locations are not covered.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 002 NC (PPO) covers emergency services with a $115 copay and no coinsurance, with the copay waived if admitted to the hospital within 24 hours. Urgently needed services range from no copay to a $40 copay with no coinsurance, while worldwide emergency services are covered up to $25,000 with a $115 copay and no coinsurance for emergency or urgent care, and a $350 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 002 NC (PPO) provides primary care physician services with no copay and no coinsurance, while specialist visits require a $45 copay and no coinsurance. Other covered benefits, including physical therapy, mental health, and telehealth services, feature copays ranging from $0 to $50 and no coinsurance, though podiatry and routine chiropractic services are not covered.
Preventive Services See details
DEVOTED CHOICE GIVEBACK 002 NC (PPO) covers preventive services with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management training. Additional preventive services are partially covered with no copay and no coinsurance, excluding in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs for chemotherapy-related hair loss, therapeutic massage, adult day health, palliative care, in-home support, caregiver support, extra smoking cessation counseling, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE GIVEBACK 002 NC (PPO), featuring routine hearing exams for a $45 copay and no coinsurance, and prescription hearing aids with a copay of $599 to $899 and no coinsurance. OTC hearing aids, along with inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
DEVOTED CHOICE GIVEBACK 002 NC (PPO) provides partially covered vision services with no deductibles or coinsurance, featuring a $0 to $45 copay for routine eye exams and no copay for eyewear. While routine eye exams (one per year) and eyewear (up to a $200 annual limit) are covered, other eye exam services are not covered.
Dental Services See details
Dental Services are partially covered by DEVOTED CHOICE GIVEBACK 002 NC (PPO), with Medicare-covered dental requiring a $45 copay and no coinsurance, and other covered services having no copay and no coinsurance up to a $250 annual maximum. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 002 NC (PPO) covers home infusion bundled services with no copay, although prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs have no coinsurance to 20% coinsurance, while insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 002 NC (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED CHOICE GIVEBACK 002 NC (PPO) with no copays and coinsurance ranging from no coinsurance to 20%, though diabetic therapeutic shoes and inserts are not covered. Prior authorization is required, and durable medical equipment is subject to a 20% coinsurance.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 002 NC (PPO) covers diagnostic and radiological services, with prior authorization required for both. Lab services, outpatient X-rays, and diagnostic radiological services have no copays, while diagnostic procedures and tests have no coinsurance and a copay ranging from $0 to $95. Therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED CHOICE GIVEBACK 002 NC (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE GIVEBACK 002 NC (PPO) does not cover cardiac rehabilitation services, including intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET).
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by DEVOTED CHOICE GIVEBACK 002 NC (PPO) with no coinsurance, requiring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and while a prior three-day inpatient hospital stay is not necessary for admission, additional days beyond the standard 100 days are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 002 NC (PPO) partially covers other services, offering no copay and no coinsurance for Over-the-Counter (OTC) items up to $116 every three months and additional preventive services. Under this benefit, acupuncture, meal benefits, and other services 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