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DEVOTED CHOICE 005 NC (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE 005 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 005 NC (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE 005 NC (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Western North Carolina. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE 005 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 005 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 005 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 $8950.00 (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 $8950.00 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 005 NC (PPO) prescription drug plan features an annual drug deductible of $370. For Tier 1 (Preferred Generic) and Tier 2 (Generic) medications, you will pay no copay for one-, two-, or three-month supplies filled at standard retail pharmacies or through standard mail order. Brand-name and specialty drugs are subject to coinsurance rather than flat copays under this plan. You will pay a 19% coinsurance for Tier 3 (Preferred Brand) drugs, a 25% coinsurance for Tier 4 (Non-Preferred) drugs, and a 28% coinsurance for Tier 5 (Specialty) drugs, which are limited to a one-month supply. This clear cost-sharing structure helps you easily project your prescription expenses with the DEVOTED CHOICE 005 NC (PPO) plan.
Additional Benefits
The DEVOTED CHOICE 005 NC (PPO) plan provides comprehensive medical coverage with predictable out-of-pocket costs, featuring no copay and no coinsurance for primary care visits and routine preventive services. For hospital care, inpatient stays require a $395 daily copay for the first five days and no copay thereafter, while outpatient hospital services feature copays ranging from $0 to $495. Emergency room visits carry a $130 copay, which is waived if you are admitted to the hospital within 24 hours. This plan also includes valuable supplemental coverage, offering no copay or coinsurance for preventive dental care up to a $2,500 annual limit and a $300 annual allowance for eyewear with no copay. Routine hearing exams require a $30 copay, and prescription hearing aids are covered with copays between $399 and $699. Additionally, members benefit from a $50 quarterly allowance for over-the-counter items and no copay or coinsurance for home health services.
Inpatient Hospital See details
DEVOTED CHOICE 005 NC (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $395 daily copay for days 1 through 5 and no copay for days 6 through 90. Unlimited additional acute days are covered, but additional psychiatric days, hospital upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED CHOICE 005 NC (PPO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital copays range from $0 to $495, observation services carry a $395 copay per stay, and outpatient substance abuse sessions require a $30 copay, with prior authorization required for these services.
Partial Hospitalization See details
DEVOTED CHOICE 005 NC (PPO) covers partial hospitalization services with a $60.00 copay and no coinsurance. Prior authorization is required for this covered benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE 005 NC (PPO) covers ground ambulance services with a copay of $0 to $325 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required for both. While some transportation services are covered, trips to plan-approved or any other health-related locations are not covered.
Emergency Services See details
DEVOTED CHOICE 005 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 have no coinsurance and a copay ranging from no copay to $45, while worldwide emergency services are covered up to $25,000 with copays up to $325 and 20% coinsurance for transportation.
Primary Care See details
Primary care benefits are partially covered by DEVOTED CHOICE 005 NC (PPO), as podiatry and chiropractic services are not covered. Covered primary care physician services have no copay and no coinsurance, while other services like specialist visits, therapy, and mental health care require copays ranging from $0 to $50 and no coinsurance.
Preventive Services See details
DEVOTED CHOICE 005 NC (PPO) covers preventive services, including annual physical exams and kidney disease education, with no copay and no coinsurance. Additional preventive services are partially covered with no copay and no coinsurance, but exclude PERS, in-home safety assessments, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE 005 NC (PPO), featuring routine hearing exams for a $30 copay and no coinsurance, with no deductible. While up to two prescription hearing aids are covered per year with copays ranging from $399 to $699 and no coinsurance, OTC hearing aids and inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
DEVOTED CHOICE 005 NC (PPO) vision services are partially covered, offering one routine eye exam per year with a $0 to $30 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, up to a combined annual maximum benefit of $300 for contacts, lenses, frames, and upgrades.
Dental Services See details
Dental services are partially covered under the DEVOTED CHOICE 005 NC (PPO) up to a $2,500 annual limit, featuring no copay and no coinsurance for preventive care, periodontics, and oral surgery. Restorative and endodontic services require no copay with 0% to 50% coinsurance, while Medicare-covered dental has a $30 copay and no coinsurance; however, implants, orthodontics, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE 005 NC (PPO) covers Home Infusion bundled Services with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs have no copay and 0% (no coinsurance) to 20% coinsurance, while Part B insulin is covered with a $35 copay and 0% (no coinsurance) to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CHOICE 005 NC (PPO) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
DEVOTED CHOICE 005 NC (PPO) partially covers medical equipment with no copay, though prior authorization is required for these services. Durable medical equipment carries a 20% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance to 20% coinsurance; however, diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under DEVOTED CHOICE 005 NC (PPO) with no coinsurance and no copay for lab services, while diagnostic tests require a copay ranging from no copay to $95. Outpatient X-rays require no copay, diagnostic radiology starts with no copay, and therapeutic radiology requires a minimum 20% coinsurance, with prior authorization required for all services.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE 005 NC (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE 005 NC (PPO) covers some Cardiac Rehabilitation Services with no coinsurance, although cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for PAD services are not covered. These services require prior authorization and carry a copayment of $25 to $30.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE 005 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. Prior authorization is required, and additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
Other services are partially covered by DEVOTED CHOICE 005 NC (PPO), offering no copay and no coinsurance for additional preventive services and over-the-counter (OTC) items, which include a $50 allowance every three months. Acupuncture and meal benefits are not covered.
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