A non-government entity
DEVOTED CHOICE 003 NC (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE 003 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 003 NC (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE 003 NC (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in North Carolina Triad. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE 003 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 003 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 003 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 $5900.00 (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 $5900.00 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 003 NC (PPO) Medicare plan features an annual drug deductible of $370. Beneficiaries enjoy no copay for Tier 1 preferred generic and Tier 2 generic drugs filled at standard pharmacies or through standard mail order. For higher-tier medications, costs are based on coinsurance for both standard retail pharmacy and standard mail-order fills. You will pay 19% coinsurance for Tier 3 preferred brand drugs, 25% coinsurance for Tier 4 non-preferred drugs, and 28% coinsurance for Tier 5 specialty drugs.
Additional Benefits
The DEVOTED CHOICE 003 NC (PPO) plan offers robust coverage with no copay for primary care visits, preventive services, and home health care. For specialist visits, members pay a $30 copay, while inpatient hospital stays require a $325 daily copay for the first six days and no copay for days seven through ninety. Emergency room visits carry a $130 copay, which is waived if you are admitted to the hospital within 24 hours. This plan also features generous dental coverage with no copay up to a $2,500 annual limit, and eyewear is covered with no copay up to a $300 yearly maximum. Routine hearing exams require a $30 copay, and prescription hearing aids are available with copays ranging from $399 to $699. Additionally, members can access over-the-counter health items with no copay up to a $50 maximum benefit every three months.
Inpatient Hospital See details
DEVOTED CHOICE 003 NC (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $325 daily copay for days 1 through 6 and no copay for days 7 through 90 for both acute and psychiatric stays. Unlimited additional acute days are covered, but upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE 003 NC (PPO) covers outpatient services with no coinsurance, although prior authorization is required for most services. Outpatient hospital copays range from $0 to $425, observation services require a $325 copay per stay, and substance abuse sessions have a $30 copay, while ambulatory surgical center and blood services are covered with no copay.
Partial Hospitalization See details
Partial hospitalization services are covered by DEVOTED CHOICE 003 NC (PPO) with a $60.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE 003 NC (PPO) covers ambulance services with prior authorization, offering ground ambulance services with a copay ranging from no copay to $325 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
DEVOTED CHOICE 003 NC (PPO) covers emergency services with a $130 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 $45 copay with no coinsurance, while worldwide emergency services are covered up to a $25,000 limit with a $130 copay for emergency or urgent care and a $325 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE 003 NC (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $30 copay and no coinsurance. Physical, occupational, and speech therapies have a $30 to $50 copay and no coinsurance, and mental health services carry a $30 copay and no coinsurance. Podiatry is not covered, and chiropractic care is only partially covered with a $15 copay, no coinsurance, and routine services excluded.
Preventive Services See details
DEVOTED CHOICE 003 NC (PPO) preventive services are covered with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes training. Additional preventive benefits are partially covered with no copay or coinsurance, offering fitness and nutritional programs but excluding services like personal emergency response systems, therapeutic massages, and in-home support.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE 003 NC (PPO), offering routine exams for a $30 copay and no coinsurance, and prescription hearing aids for a $399 to $699 copay and no coinsurance. However, OTC hearing aids and inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
DEVOTED CHOICE 003 NC (PPO) partially covers vision services, offering one annual routine eye exam with a copay of up to $30 and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance, up to a combined maximum benefit of $300 per year for contacts, eyeglasses, and upgrades.
Dental Services See details
Dental services covered by DEVOTED CHOICE 003 NC (PPO) include preventive and select comprehensive care with no copay and no coinsurance, up to a combined $2,500 annual maximum. Other comprehensive services have no copay and 0% to 50% coinsurance, while Medicare-covered dental has a $30 copay and no coinsurance; however, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED CHOICE 003 NC (PPO) with no copay, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs require no coinsurance to 20% coinsurance, while Medicare Part B insulin drugs have a $35 copay and up to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by DEVOTED CHOICE 003 NC (PPO) with no copay and a 20% coinsurance. Prior authorization is required to receive these services.
Medical Equipment See details
DEVOTED CHOICE 003 NC (PPO) partially covers medical equipment with no copay, requiring 20% to 30% coinsurance for durable medical equipment and no coinsurance to 20% coinsurance for prosthetics and medical supplies. Diabetic supplies are covered with no copay and no coinsurance to 30% coinsurance, but diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services under DEVOTED CHOICE 003 NC (PPO) require prior authorization, with lab services and outpatient X-rays available with no copay. Diagnostic procedures and tests feature no coinsurance and a copay ranging from $0 to $95, while therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED CHOICE 003 NC (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE 003 NC (PPO) covers cardiac rehabilitation services with no coinsurance, though some services are covered while cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE 003 NC (PPO) covers Skilled Nursing Facility (SNF) care with no coinsurance and does not require a prior three-day inpatient hospital stay, though prior authorization is required. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, with additional days beyond the standard Medicare-covered limit not covered.
Other Services See details
Other services are partially covered by DEVOTED CHOICE 003 NC (PPO), as acupuncture and meal benefits are not covered. Covered benefits include additional preventive services and over-the-counter (OTC) items with no copay and no coinsurance, which features a $50 maximum benefit coverage limit every three months for OTC products.
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