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DEVOTED CHOICE GIVEBACK 009 NC (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 009 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 009 NC (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 009 NC (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Northwestern/Southeastern North Carolina. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 009 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 009 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 009 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 $180.00. 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 $13900.00 (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 $13900.00 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 009 NC (PPO) Medicare plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs are highly affordable, requiring no copay for up to a three-month supply at standard pharmacies or through standard mail order. For Tier 2 generic drugs, you can expect a low copay starting at $3.00 for a one-month supply, with standard mail order offering a discounted three-month supply copay of $7.50. For brand-name and specialty medications, costs transition to coinsurance percentages. Tier 3 preferred brand drugs require a 21% coinsurance for standard retail and mail-order fills. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance, helping you plan for your higher-tier prescription expenses under this PPO plan.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 009 NC (PPO) plan offers robust coverage with many essential healthcare services available at no cost. Members enjoy no copay or coinsurance for primary care visits, preventive care, home health services, and diagnostic lab tests or X-rays. For more extensive care, inpatient hospital stays require a $475 daily copay for the first four days and no copay thereafter, while specialist visits have a $55 copay. Additional benefits include emergency room visits with a $115 copay, which is waived upon admission, and urgent care ranging from no copay to a $40 copay. The plan also covers routine eye exams and eyewear up to a $200 annual limit with no copay, as well as preventive dental care up to a $250 limit with no copay. Skilled nursing facility stays offer no copay for the first 20 days, followed by a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 009 NC (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $475 daily copay for days 1 through 4 and no copay for days 5 through 90. Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 009 NC (PPO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital services have a copay ranging from $0 to $475 (with a $475 copay per stay for observation), and outpatient substance abuse sessions require a $50 copay.
Partial Hospitalization See details
Partial hospitalization is covered under the DEVOTED CHOICE GIVEBACK 009 NC (PPO) plan with a $70.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 009 NC (PPO) covers ground ambulance services with a copay ranging from no copay to $315 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, both requiring prior authorization. Transportation services to health-related locations are not covered.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 009 NC (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services range from no copay to a $40 copay with no coinsurance, while worldwide emergency services are covered up to $25,000 with copays ranging from $115 to $315 and coinsurance up to 20% for transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 009 NC (PPO) offers primary care physician services with no copay and no coinsurance, while specialist visits require a $55 copay and no coinsurance. Other covered benefits include physical therapy ($55 copay), occupational therapy ($35 copay), mental health services ($50 copay), and telehealth ($0 to $55 copay) with no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
DEVOTED CHOICE GIVEBACK 009 NC (PPO) offers preventive services with no copay and no coinsurance for covered services, including annual physical exams, fitness benefits, and kidney disease education. However, the benefit is only partially covered, as exclusions apply to services like in-home safety assessments, personal emergency response systems, medical nutrition therapy, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, and counseling.
Hearing Services See details
DEVOTED CHOICE GIVEBACK 009 NC (PPO) covers hearing services, including one annual routine exam for a $55 copay and no coinsurance with no deductible, and unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a $599 to $899 copay for up to two devices per year, but inner ear, outer ear, over-the-ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
DEVOTED CHOICE GIVEBACK 009 NC (PPO) partially covers vision services with no deductibles, offering one routine eye exam per year with a $0 to $20 copay and no coinsurance, while other eye exam services are not covered. Eyewear, including contacts, eyeglasses, and upgrades, is covered with no copay and no coinsurance up to a combined $200 annual limit.
Dental Services See details
DEVOTED CHOICE GIVEBACK 009 NC (PPO) offers partially covered dental services with no copay and no coinsurance for preventive and most comprehensive care up to a $250 annual limit. Medicare-covered dental services require a $55 copay and no coinsurance, but maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 009 NC (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other infusion drugs require no coinsurance to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by DEVOTED CHOICE GIVEBACK 009 NC (PPO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED CHOICE GIVEBACK 009 NC (PPO) with no copayments, though prior authorization is required. Covered durable medical equipment has a 16% coinsurance, while prosthetic devices, medical supplies, and diabetic supplies range from no coinsurance to up to 20% coinsurance; diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 009 NC (PPO) covers diagnostic and radiological services, offering lab services, outpatient X-rays, and diagnostic radiological services with no copay. Diagnostic procedures and tests have a copay ranging from $0 to $95 with no coinsurance, while therapeutic radiological services require a 20% coinsurance, and prior authorization is required.
Home Health Services See details
Home Health Services are covered by DEVOTED CHOICE GIVEBACK 009 NC (PPO) with no copay and no coinsurance. Prior authorization is required to receive these services.
Cardiac Rehabilitation Services See details
Some Cardiac Rehabilitation Services are covered under the DEVOTED CHOICE GIVEBACK 009 NC (PPO) plan with no coinsurance and require prior authorization, but cardiac, intensive cardiac, pulmonary, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 009 NC (PPO) covers Skilled Nursing Facility (SNF) services 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, with no coverage for additional days.
Other Services See details
DEVOTED CHOICE GIVEBACK 009 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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