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DEVOTED CHOICE GIVEBACK 002 NE (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 002 NE (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 002 NE (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 002 NE (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Nebraska. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 002 NE (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 002 NE (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 002 NE (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 $159.80. 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 $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 002 NE (PPO) plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs are highly affordable, offering no copay for one-, two-, or three-month supplies through standard pharmacies and standard mail order. For Tier 2 generic medications, you will pay a low copay starting at $3.00 for a one-month supply, with standard mail order offering a discounted $7.50 copay for a three-month supply. Brand-name and specialty medications on higher tiers require coinsurance instead of flat copays. Tier 3 preferred brand drugs carry a 21% coinsurance for standard pharmacy and mail-order fills. Tier 4 non-preferred drugs and Tier 5 specialty drugs both require 25% coinsurance, with specialty drugs limited to a one-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 002 NE (PPO) plan offers affordable coverage for core medical needs, featuring no copay and no coinsurance for primary care doctor visits and preventive services. For inpatient hospital stays, members pay a $475 daily copay for days one through four and no copay for days five through 90, with no coinsurance. Specialist visits require a $55 copay, and emergency room care is covered with a $115 copay that is waived upon hospital admission. Supplemental benefits under this plan include home health services with no copay and dental care with no copay for most preventive and comprehensive options up to a $250 annual limit. Routine vision eyewear has no copay up to a $200 yearly limit, while hearing aids are covered with copays between $599 and $899. Diagnostic lab tests and outpatient X-rays are also fully covered with no copay, ensuring comprehensive care with predictable out-of-pocket costs.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 002 NE (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $475 daily copay for days 1 through 4 and no copay for days 5 through 90. While unlimited additional acute care days are covered, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 002 NE (PPO) covers outpatient services with no coinsurance, offering no copays for ambulatory surgical center and blood services, and a $50 copay for outpatient substance abuse sessions. Outpatient hospital services have a copay ranging from $0 to $475, while observation services require a $475 copay per stay, with prior authorization needed for most services.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 002 NE (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 002 NE (PPO) covers ground ambulance services with a copay ranging from no copay to $300 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Prior authorization is required for ambulance services, and transportation services are not covered.
Emergency Services See details
Emergency services are covered by DEVOTED CHOICE GIVEBACK 002 NE (PPO) with a $115 copay and no coinsurance, with the copay 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, and worldwide emergency services are covered up to $25,000 with a $115 copay and no coinsurance for emergency or urgent care, and a $300 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 002 NE (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $55 copay and no coinsurance. Outpatient therapies, psychiatric services, and telehealth are covered with copays ranging from $0 to $55 and no coinsurance, though podiatry is not covered and only some chiropractic services are covered as routine and other chiropractic services are not covered.
Preventive Services See details
DEVOTED CHOICE GIVEBACK 002 NE (PPO) offers partially covered preventive services with no copay and no coinsurance for covered benefits like annual physicals, kidney disease education, and fitness benefits. Non-covered sub-services include in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional tobacco cessation counseling, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
DEVOTED CHOICE GIVEBACK 002 NE (PPO) covers hearing services, featuring one annual routine hearing exam for a $55 copay and no coinsurance, alongside unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $599 to $899 for up to two devices per year, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE GIVEBACK 002 NE (PPO), which offers one routine eye exam per year with a $0 to $20 copay and no coinsurance, while other eye exam services are not covered. Covered eyewear, including lenses, frames, and contacts, has no copay or coinsurance and is subject to a $200 annual combined maximum limit.
Dental Services See details
DEVOTED CHOICE GIVEBACK 002 NE (PPO) partially covers dental services with no copay and no coinsurance for most preventive and comprehensive options, subject to a $250 combined annual maximum. Medicare-covered dental services require a $55 copay and no coinsurance, while implants, orthodontics, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by DEVOTED CHOICE GIVEBACK 002 NE (PPO) with no copay, though associated Medicare Part B chemotherapy, radiation, and other drugs carry a 0% to 20% coinsurance. Covered Part B insulin drugs require a $35 copay and a 0% to 20% coinsurance, and prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered by DEVOTED CHOICE GIVEBACK 002 NE (PPO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Medical equipment benefits under the DEVOTED CHOICE GIVEBACK 002 NE (PPO) plan are covered with no copays, though prior authorization is required. Durable medical equipment carries a 15% coinsurance, prosthetic devices and medical supplies range from no coinsurance to 20% coinsurance, and diabetic equipment is partially covered, offering diabetic supplies with no coinsurance to 15% coinsurance, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 002 NE (PPO) covers diagnostic and radiological services, with prior authorization required for both. Diagnostic services feature no coinsurance, offering lab services with no copay and diagnostic procedures with a copay ranging from $0 to $95. Radiological services include outpatient X-rays with no copay, diagnostic radiology with a $0 minimum copay, and therapeutic radiology with a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE GIVEBACK 002 NE (PPO) plan with no copay and no coinsurance. Prior authorization is required to access these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered with no coinsurance under the DEVOTED CHOICE GIVEBACK 002 NE (PPO) plan, though prior authorization is required. Some services are covered, but cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 002 NE (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, no prior three-day hospital stay is needed, and additional days beyond the standard 100-day Medicare benefit period are not covered.
Other Services See details
Other services are partially covered by DEVOTED CHOICE GIVEBACK 002 NE (PPO), which offers coverage for 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.
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