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Devoted CHOICE North Carolina (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE 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 North Carolina (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE North Carolina (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 2025.
It's important to know that Devoted CHOICE 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 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 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.
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 $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 $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 North Carolina (PPO) plan has an enhanced alternative drug benefit. The plan has a $590 deductible for prescription drugs. During the initial coverage phase, after the deductible is met, you'll pay either a copay or coinsurance depending on the drug tier and pharmacy used. For example, you pay no copay for preferred generic drugs through standard or mail order pharmacies. For all other tiers, the coinsurance is 25% at both standard and mail order pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs.
Additional Benefits
The Devoted CHOICE North Carolina (PPO) plan offers coverage for a wide range of services, including inpatient and outpatient hospital care with varying copays. Emergency, primary care, preventive, hearing, vision, and dental services are also included, with copays for many services. The plan also covers home infusion, dialysis, medical equipment, and diagnostic services. Additional benefits include ambulance services, skilled nursing facility care, and home health services. While some services like cardiac rehabilitation, and several "other services" are not covered, this plan provides a comprehensive package with a variety of cost-sharing options such as copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital services are covered, including services not usually covered by Medicare plans. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you'll pay a $395 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services includes coverage for all outpatient hospital services, with a copay between $0 and $495, and observation services with a $395 copay. Ambulatory Surgical Center (ASC) Services have no copay, and outpatient substance abuse services have a $40 copay for both individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE North Carolina (PPO) plan, with a $60 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a copay of $0-$300, while air ambulance services have a 20% coinsurance. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Devoted CHOICE North Carolina (PPO) plan. Emergency Services has a $125 copay, Urgently Needed Services has a copay between $0 and $45, and Worldwide Emergency Transportation has a $300 copay and 20% coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage each have a $125 copay.
Primary Care See details
Primary Care Physician 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 are covered. Chiropractic Services has a $20 copay. Occupational Therapy Services, Individual and Group Sessions for Mental Health Specialty Services, Individual and Group Sessions for Psychiatric Services, and Opioid Treatment Program Services have a copay between $40 and $45. Physical Therapy and Speech-Language Pathology Services have a copay between $40 and $50. Additional Telehealth Benefits have a copay between $0 and $40. Podiatry Services are not covered.
Preventive Services See details
The Devoted CHOICE North Carolina (PPO) plan covers several preventive services, including health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit, with no copay. However, in-home safety assessment, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss, 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, and counseling services are not covered.
Hearing Services See details
Hearing services are covered, including hearing exams with a $35 copay. Prescription hearing aids are covered, with a copay between $399 and $699, while inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision services include eye exams, with a $35 copay, and routine eye exams are covered once per year. Eyewear is covered with a combined maximum benefit of $1000 per year for both in-network and out-of-network services, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental services include Medicare dental services with a $40 copay, while other dental services have a $1,000 maximum benefit per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Devoted CHOICE North Carolina (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME) with no copay and 0-20% coinsurance, and Prosthetic Devices with 0-20% coinsurance and no copay. Durable Medical Equipment for use outside the home and Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures/tests, lab services, and radiological services. Diagnostic procedures/tests have a copay that ranges from $0 to $95, lab services have no copay, and diagnostic radiological services have a copay of up to $300. Therapeutic radiological services have a coinsurance of at least 20%, while outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE North Carolina (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted CHOICE North Carolina (PPO) plan. Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are also not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE North Carolina (PPO) plan, but prior authorization is required. You will have no copay for days 1-20 and days 61-100, but a $214 copay for days 21-60. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Devoted CHOICE North Carolina (PPO) plan's "Other Services" benefit does not cover acupuncture, over-the-counter (OTC) items, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, 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. Other services may be covered.
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