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DEVOTED CHOICE GIVEBACK 006 NC (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 006 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 006 NC (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 006 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 GIVEBACK 006 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 006 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 006 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 $174.80. 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 006 NC (PPO) Medicare plan has an annual drug deductible of $605. Tier 1 preferred generic drugs are fully covered with no copay for one-, two-, or three-month fills at standard pharmacies and through standard mail order. Tier 2 generic drugs carry a low standard copay starting at $3.00 for a one-month supply, up to $9.00 for a three-month standard pharmacy supply, or $7.50 for a three-month standard mail order supply. For brand-name and specialty medications, costs are based on coinsurance rather than set copays. Tier 3 preferred brand drugs require a 21% coinsurance for all supply durations at standard pharmacies and standard mail order. Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance, though Tier 5 coverage is limited to a one-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 006 NC (PPO) plan offers robust coverage for essential medical needs with predictable out-of-pocket costs. You will pay no copay and no coinsurance for primary care visits, home health services, and annual physical exams, while specialist visits require a $45 copay. Inpatient hospital stays feature a daily copay of $440 for the first few days and no copay thereafter, while emergency room visits carry a $115 copay that is waived if you are admitted. For supplemental care, this plan provides preventive and comprehensive dental services with no copay up to a $250 annual limit, alongside eyewear coverage with no copay up to a $200 yearly maximum. Routine hearing exams are available for a $45 copay, and diagnostic lab services and outpatient X-rays are covered with no copay. Medical equipment and dialysis services generally require a 20% coinsurance, ensuring you have access to necessary supplies and treatments.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 006 NC (PPO) covers inpatient hospital services with no coinsurance, requiring a daily copay of $440 for days 1 to 5 of acute stays and days 1 to 4 of psychiatric stays, followed by no copay for remaining days. Prior authorization is required, and upgrades or non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 006 NC (PPO) covers outpatient services with no coinsurance, featuring a $0 to $540 copay for hospital services and a $440 copay per stay for observation services. Ambulatory surgical center and outpatient blood services are covered with no copays and no coinsurance, while outpatient substance abuse sessions require a $45 copay and no coinsurance.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 006 NC (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to access this covered benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 006 NC (PPO) covers ambulance services with prior authorization, requiring a copay ranging from no copay to $350 for ground transport and a 20% coinsurance for air transport. For transportation benefits, some services are covered, but trips to plan-approved or any health-related locations are not covered.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 006 NC (PPO) covers emergency services with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no copay to a $40 copay and no coinsurance, while worldwide emergency services are covered up to $25,000 with a $115 copay for emergency or urgent care and a $350 copay and 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 006 NC (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $45 copay and no coinsurance. Standard therapies and mental health services require copays ranging from $35 to $50 with no coinsurance, while podiatry is not covered. Additionally, some chiropractic services are covered with a $15 copay and no coinsurance, but routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services are covered by DEVOTED CHOICE GIVEBACK 006 NC (PPO) with no copay and no coinsurance, including annual physical exams and kidney disease education. However, additional preventive benefits are only partially covered, excluding in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, therapeutic massage, adult day health, palliative care, in-home support, caregiver support, smoking cessation counseling, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
DEVOTED CHOICE GIVEBACK 006 NC (PPO) offers partially covered hearing services with no deductible, including one routine hearing exam per year for a $45 copay and no coinsurance. Up to two prescription hearing aids are covered per year with a copay of $599 to $899 and no coinsurance, while inner ear, outer ear, over the ear, and over-the-counter hearing aids are not covered.
Vision Services See details
DEVOTED CHOICE GIVEBACK 006 NC (PPO) covers one routine eye exam per year with a copay ranging from no copay to $45 and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, up to a combined maximum benefit of $200 per year for contacts, lenses, frames, and upgrades.
Dental Services See details
DEVOTED CHOICE GIVEBACK 006 NC (PPO) offers partially covered dental services, featuring Medicare-covered dental care for a $45 copay and no coinsurance, alongside preventive and comprehensive dental care with no copay and no coinsurance up to a $250 annual limit. Maxillofacial prosthetics, implant services, and orthodontics are not covered under this plan.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 006 NC (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs require between no coinsurance and 20% coinsurance, while Part B insulin has a $35 copay and up to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the DEVOTED CHOICE GIVEBACK 006 NC (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Medical equipment is covered under the DEVOTED CHOICE GIVEBACK 006 NC (PPO) with no copays, featuring a 20% coinsurance for durable medical equipment and ranging from no coinsurance to 20% coinsurance for prosthetics, medical supplies, and diabetic supplies. This benefit is partially covered because diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 006 NC (PPO) covers diagnostic and radiological services with prior authorization required, offering lab services and outpatient X-rays with no copay. Diagnostic procedures feature no coinsurance and a copay ranging from $0 to $95, while diagnostic radiological services start with no copay and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
DEVOTED CHOICE GIVEBACK 006 NC (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE GIVEBACK 006 NC (PPO) covers some cardiac rehabilitation services with no coinsurance, requiring prior authorization. However, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by DEVOTED CHOICE GIVEBACK 006 NC (PPO) with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, while additional days beyond the Medicare limit are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 006 NC (PPO) partially covers other services, offering additional preventive services not covered by Medicare with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered under this benefit.
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