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DEVOTED CHOICE GIVEBACK 004 NC (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 004 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 004 NC (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 004 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 GIVEBACK 004 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 004 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 004 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:
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Drug Coverage
The DEVOTED CHOICE GIVEBACK 004 NC (PPO) Medicare plan features an annual drug deductible of $605. For Tier 1 preferred generic drugs, members enjoy no copay for one-month, two-month, or three-month supplies filled at standard pharmacies or through standard mail order. Tier 2 generic drugs are also highly affordable, requiring a copay of only $3.00 for a one-month supply at standard pharmacies and mail-order services. Higher-tier prescription drugs are covered via coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 21% coinsurance for all supply durations. Tier 4 non-preferred drugs and Tier 5 specialty drugs carry a 25% coinsurance, with specialty tier medications limited to a one-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 004 NC (PPO) plan offers comprehensive medical coverage featuring no copay for primary care visits, preventive services, and home health care. Specialists require a $45 copay, while inpatient hospital stays incur a $440 daily copay for the first few days before transitioning to no copay. Emergency room visits have a $115 copay, which is waived if you are admitted, and urgent care ranges from no copay to a $40 copay. For routine care, the plan provides dental benefits with no copay up to a $250 annual maximum, vision exams ranging from no copay to a $45 copay alongside a $200 eyewear allowance, and hearing aid coverage with copays between $599 and $899. Durable medical equipment requires a 20% coinsurance with no copay, and skilled nursing facilities are covered with no copay for the first 20 days. Additionally, members receive a $50 quarterly allowance for over-the-counter items with no copay.
Inpatient Hospital See details
Inpatient hospital services are covered by DEVOTED CHOICE GIVEBACK 004 NC (PPO) with no coinsurance, requiring prior authorization. For acute stays, there is a $440 daily copay for days 1-5 and no copay thereafter, whereas psychiatric stays require a $440 daily copay for days 1-4 and no copay for days 5-90. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services under DEVOTED CHOICE GIVEBACK 004 NC (PPO) are covered with no coinsurance, featuring a $0 to $540 copay for outpatient hospital services, a $440 copay per stay for observation services, and a $45 copay for substance abuse sessions. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, though prior authorization is required for most outpatient benefits.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 004 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 004 NC (PPO) covers ground ambulance services with a copay ranging from no copay to $350 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, both requiring prior authorization. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 004 NC (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are 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 (no coinsurance) for care and a $350 copay with 20% coinsurance for transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 004 NC (PPO) covers primary care visits with no copay and no coinsurance, while specialist, mental health, and psychiatric services require a $45 copay and no coinsurance. Occupational, physical, and speech therapy services have copays ranging from $35 to $50 with no coinsurance, whereas podiatry and chiropractic services are not covered.
Preventive Services See details
Preventive services are covered by DEVOTED CHOICE GIVEBACK 004 NC (PPO) with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management training. Additional preventive benefits are partially covered, excluding services such as in-home safety assessments, personal emergency response systems, medical nutrition therapy, therapeutic massage, and caregiver support.
Hearing Services See details
DEVOTED CHOICE GIVEBACK 004 NC (PPO) partially covers hearing services, which include one routine hearing exam per year for a $45 copay and no coinsurance. Up to two prescription hearing aids are covered annually with a copay ranging from $599 to $899 and no coinsurance, but OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE GIVEBACK 004 NC (PPO), which offers one routine eye exam per year with a $0 to $45 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay or coinsurance up to a $200 annual maximum limit for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED CHOICE GIVEBACK 004 NC (PPO) partially covers dental services, featuring Medicare-covered dental care for a $45 copay and no coinsurance, and other dental services with no copay and no coinsurance up to a $250 annual maximum. While preventive and restorative services are covered, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 004 NC (PPO) covers Home Infusion bundled Services with no copay, though prior authorization is required. Associated Medicare Part B drugs, such as chemotherapy and insulin, are subject to coinsurance ranging from no coinsurance up to 20%, with insulin also carrying a $35 copay.
Dialysis Services See details
The DEVOTED CHOICE GIVEBACK 004 NC (PPO) plan covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Medical equipment is covered by DEVOTED CHOICE GIVEBACK 004 NC (PPO) with no copay, though prior authorization is required and coinsurance applies to most items. Durable medical equipment (DME) is subject to a 20% coinsurance, while prosthetics, medical supplies, and diabetic supplies carry a 0% to 20% coinsurance; however, diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CHOICE GIVEBACK 004 NC (PPO) with prior authorization required. Lab services, diagnostic radiological services, and outpatient X-rays have no copay, while diagnostic procedures have a copay ranging from $0 to $95 with no coinsurance, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED CHOICE GIVEBACK 004 NC (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE GIVEBACK 004 NC (PPO) does not cover cardiac rehabilitation services, including intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for peripheral artery disease (PAD).
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by DEVOTED CHOICE GIVEBACK 004 NC (PPO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and additional days beyond the standard 100-day Medicare limit are not covered.
Other Services See details
Other Services under the DEVOTED CHOICE GIVEBACK 004 NC (PPO) plan are partially covered, offering no copay and no coinsurance for additional preventive services and over-the-counter (OTC) items up to $50 every three months. Acupuncture, meal benefits, and other select services are not covered under this benefit.
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