A non-government entity
Devoted LIBERTY CHOICE North Carolina (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted LIBERTY 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 LIBERTY CHOICE North Carolina (PPO) in 2025, please refer to our full plan details page.
Devoted LIBERTY CHOICE North Carolina (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in North Carolina. The overall rating for this plan is not yet available for 2025.
It's important to know that Devoted LIBERTY CHOICE North Carolina (PPO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Devoted LIBERTY 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 LIBERTY 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. Additionally, this plan comes with a Part B Premium reduction of $174.70. 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.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $14000.00 (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 $14000.00 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:
Sign up for Devoted LIBERTY CHOICE North Carolina (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
Prescription drugs are not covered by Devoted LIBERTY CHOICE North Carolina (PPO).
Additional Benefits
The Devoted LIBERTY CHOICE North Carolina (PPO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services with varying copays, and coverage for emergency services. Primary care visits have a $35 copay, and specialist visits are $45. The plan also covers preventive services, hearing exams, and vision services, along with dental services. This plan provides coverage for home health services, skilled nursing facilities, and cardiac rehabilitation services. Additionally, the plan covers medical equipment, diagnostic and radiological services, and offers coverage for dialysis services. However, the plan does not cover certain services like acupuncture, over-the-counter items, and private duty nursing.
Inpatient Hospital See details
Inpatient Hospital services, including acute and psychiatric care, are covered. For days 1-4, there is a $375 copay, and for days 5-90, there is no copay.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $475, Observation Services with a $425 copay, Ambulatory Surgical Center (ASC) Services with no copay, and Outpatient Substance Abuse Services with a $45 copay for both individual and group sessions. Outpatient Blood Services are also covered with a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted LIBERTY CHOICE North Carolina (PPO) plan, with a $70 copay. Prior authorization is required for coverage.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted LIBERTY CHOICE North Carolina (PPO) plan. Ground ambulance services have a copay of $0 - $350, while air ambulance services have a 20% coinsurance. 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 under the Devoted LIBERTY CHOICE North Carolina (PPO) plan. Emergency Services have a $110 copay, and Urgently Needed Services have a copay between $0 and $45. Worldwide Emergency Transportation has a $350 copay and 20% coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay.
Primary Care See details
The Devoted LIBERTY CHOICE North Carolina (PPO) plan covers primary care physician services and occupational therapy services with a $35 copay, physician specialist services for a $45 copay, and physical therapy and speech-language pathology services for a $45-$50 copay. Mental health and psychiatric services, including individual and group sessions, and opioid treatment program services have a $45 copay, and other health care professional services have a copay between $0-$45. This plan does not cover routine chiropractic care or podiatry services.
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, with no copay or coinsurance. However, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission 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, and counseling services are not covered.
Hearing Services See details
Hearing Services includes routine hearing exams with a $45 copay, and fitting/evaluation for hearing aids. Prescription hearing aids are covered with a copay between $599 and $899, with a limit of 2 per year, but prescription hearing aids - inner ear, outer ear, and over the ear, are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a $20 copay, and eyewear with a combined maximum plan benefit of $250 every year for both in-network and out-of-network services. Routine eye exams are covered once per year, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The Devoted LIBERTY CHOICE North Carolina (PPO) plan covers Medicare Dental Services with a $45 copay, and other dental services with a maximum benefit of $250 per year. The plan does not cover Maxillofacial Prosthetics, Implant Services, and Orthodontics services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. Medicare Part B Insulin Drugs have a $35 copay with 20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted LIBERTY CHOICE North Carolina (PPO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 16% coinsurance, Prosthetic Devices with 0-20% coinsurance, and Medical Supplies with 20% coinsurance; however, Durable Medical Equipment for use outside the home, 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 ranging from $0 to $95. Lab services have no copay, while diagnostic radiological services have a copay up to $300. Therapeutic radiological services have a coinsurance of at least 20%, and outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted LIBERTY CHOICE North Carolina (PPO) plan with no copay and no coinsurance, but prior authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. There is a copay for some Cardiac and Pulmonary Rehabilitation Services, but the specific cost is not provided.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted LIBERTY CHOICE North Carolina (PPO) plan, but prior authorization is required. For days 1-20 and 61-100, there is no copay, but for days 21-60, there is a $214 copay.
Other Services See details
The Devoted LIBERTY CHOICE North Carolina (PPO) plan does not cover acupuncture, over-the-counter 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, or Self-Directed Personal Assistance Services. Other services such as preventive services have no copay.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved