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Devoted CHOICE GIVEBACK North Carolina (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE GIVEBACK 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 GIVEBACK North Carolina (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE GIVEBACK 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 GIVEBACK 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 GIVEBACK 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 GIVEBACK 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. Additionally, this plan comes with a Part B Premium reduction of $147.70. 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 $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 $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 North Carolina (PPO) plan has a $590 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For drugs in the initial coverage phase, you may pay a $5 copay for preferred generic drugs at a standard or mail pharmacy. For standard generic, preferred brand, and non-preferred drugs, you will pay 25% coinsurance. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Devoted CHOICE GIVEBACK North Carolina (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, with no copay for days 6-90, while outpatient services have copays that vary by service. Emergency services have a $110 copay, and primary care services have copays between $15 and $45. The plan also includes coverage for hearing, vision, and dental services. Hearing exams have a $45 copay, and prescription hearing aids have a copay between $599 and $899. Routine eye exams have a $20 copay, and eyewear has a combined maximum benefit of $250 per year. Dental services have a $45 copay, with a maximum benefit of $250 per year.
Inpatient Hospital See details
Inpatient Hospital services, including acute and psychiatric, are covered with prior authorization. For the first 5 days of an inpatient stay, the copay is $365 per day, and there is no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered stay 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 Outpatient Hospital Services with a copay between $0 and $465, Observation Services with a $440 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a $45 copay for both individual and group sessions, and Outpatient Blood Services with a waived three-pint deductible. Prior authorization is required for some services.
Partial Hospitalization See details
Partial Hospitalization is covered under the Devoted CHOICE GIVEBACK North Carolina (PPO) plan, with a $70 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted CHOICE GIVEBACK North Carolina (PPO) plan, with prior authorization required for all ambulance services. Ground ambulance services have a copay between $0 and $350, while air ambulance services have a 20% coinsurance, and transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Devoted CHOICE GIVEBACK North Carolina (PPO) plan. Emergency Services have a $110 copay, and no coinsurance. Urgently Needed Services have a copay between $0 and $45, and no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, and no coinsurance. Worldwide Emergency Transportation has a $350 copay and 20% coinsurance.
Primary Care See details
The Devoted CHOICE GIVEBACK North Carolina (PPO) plan covers primary care physician services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy, speech-language pathology services, opioid treatment program services, and additional telehealth benefits. Chiropractic services have a $15 copay, while physician specialist services have a $45 copay, and physical therapy and speech-language pathology services have a $45-$50 copay.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. In-home safety assessments, Personal Emergency Response Systems (PERS), Medical Nutrition Therapy (MNT), post-discharge in-home medication reconciliation, readmission prevention, wigs for hair loss related to chemotherapy, 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 include hearing exams with a $45 copay, and prescription hearing aids with a copay between $599 and $899. Routine hearing exams and fitting/evaluation for hearing aids are covered, while prescription hearing aids for inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams with a $20 copay, and eyewear with a combined maximum benefit of $250 per year for both in and out-of-network services. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $45 copay, as well as other dental services. Other covered dental services include 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, prosthodontics, fixed, and oral and maxillofacial surgery. Maxillofacial prosthetics, implant services, and orthodontics are not covered. The plan has a maximum benefit of $250 per year for both in-network and out-of-network services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 20% coinsurance, Medicare Part B Chemotherapy/Radiation Drugs with between 0% and 20% coinsurance, and Other Medicare Part B Drugs with between 0% and 20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE GIVEBACK North Carolina (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 17% coinsurance and no copay, though Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a coinsurance, while Prosthetic Devices have a 0-20% coinsurance and no copay. Diabetic Equipment is covered, but 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, with a copay that ranges from $0 to $95. Lab services have no copay, while diagnostic radiological services have a copay of at most $300, and therapeutic radiological services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK North Carolina (PPO) plan, with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted CHOICE GIVEBACK North Carolina (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE GIVEBACK North Carolina (PPO) plan, with prior authorization required. There is no copay for days 1-20 and days 61-100, but there is a $214 copay for days 21-60. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services offered by the Devoted CHOICE GIVEBACK North Carolina (PPO) plan do not cover acupuncture, over-the-counter items, and meal benefits, as well as several other services including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and Case Management (Long Term Care). Other 2 benefits are covered, and include $0 preventive services.
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