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DEVOTED CHOICE GIVEBACK 013 FL (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 013 FL (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 013 FL (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 013 FL (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Escambia, Santa Rosa Counties. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 013 FL (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 013 FL (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 013 FL (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 $184.70. 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 $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 013 FL (PPO) plan features an annual prescription drug deductible of $605. Under this plan, Tier 1 preferred generic drugs have no copay for a 1-month, 2-month, or 3-month supply at standard pharmacies and through standard mail order. Tier 2 generic drugs are also highly affordable, with standard retail and mail-order copays starting at just $3.00 for a 1-month supply. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 22% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance for a 1-month supply. These coinsurance rates apply to both standard retail pharmacies and standard mail-order services.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 013 FL (PPO) plan offers comprehensive medical coverage featuring no copay for primary care visits, home health services, and preventive care. For specialized care, members can expect a $45 copay for specialist visits and a $450 daily copay for the first four days of inpatient hospital stays, with no copay required for days five through 90. Emergency services are available with a $115 copay, while urgent care visits range from a $0 to $40 copay. This plan also includes valuable supplemental benefits, such as dental care up to a $1,000 annual maximum with no copay for preventive services, and a $200 yearly allowance for eyewear. Additionally, members receive a $120 over-the-counter allowance every three months and partial coverage for prescription hearing aids. Essential diagnostics like lab services and outpatient X-rays are also covered with no copay.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 013 FL (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $450 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
Outpatient services under DEVOTED CHOICE GIVEBACK 013 FL (PPO) are covered with no coinsurance, featuring a $0 to $550 copay for hospital services and a $450 copay per stay for observation services. Ambulatory surgical center and blood services have no copay and no coinsurance, while outpatient substance abuse sessions require a $45 copay with no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered under the DEVOTED CHOICE GIVEBACK 013 FL (PPO) plan with an $80 copay and no coinsurance. Prior authorization is required to receive these covered services.
Ambulance and Transportation Services See details
Ambulance services are covered by DEVOTED CHOICE GIVEBACK 013 FL (PPO) with a $0 to $350 copay and no coinsurance for ground transport, and a 20% coinsurance with no copay for air transport, with prior authorization required. Transportation services to plan-approved or any health-related locations are not covered under this plan.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 013 FL (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 have a $0 to $40 copay and no coinsurance, while worldwide emergency services are covered up to $25,000 with a $115 copay and no coinsurance for emergency or urgent care, and a $350 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 013 FL (PPO) offers primary care physician services with no copay and no coinsurance, and specialist visits with a $45 copay and no coinsurance. Therapy and mental health services require copays ranging from $35 to $50 with no coinsurance, while podiatry is not covered, and for chiropractic, some services are covered but routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by DEVOTED CHOICE GIVEBACK 013 FL (PPO) with no copay and no coinsurance for covered care, including annual physical exams, fitness benefits, and nutritional counseling. However, several sub-services are not covered, including in-home safety assessments, therapeutic massage, personal emergency response systems (PERS), and in-home support services.
Hearing Services See details
DEVOTED CHOICE GIVEBACK 013 FL (PPO) covers hearing services, including one annual routine hearing exam with a $45 copay and no coinsurance, alongside unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and copayments ranging from $599.00 to $899.00 for up to two devices per year, while OTC hearing aids and inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE GIVEBACK 013 FL (PPO), offering one annual routine eye exam with a $0 to $45 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no deductible, no copay, and no coinsurance up to a combined $200 yearly limit for contacts, eyeglasses, frames, lenses, and upgrades.
Dental Services See details
DEVOTED CHOICE GIVEBACK 013 FL (PPO) partially covers dental services with a $1,000 annual maximum benefit, offering preventive care, periodontics, and oral surgery with no copay and no coinsurance. Restorative, endodontic, and prosthodontic services have no copay and 0% to 50% coinsurance, while Medicare-covered dental requires a $45 copay and no coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 013 FL (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CHOICE GIVEBACK 013 FL (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 013 FL (PPO) partially covers medical equipment with no copays, requiring prior authorization for all services. Durable medical equipment incurs a 20% coinsurance, while covered prosthetics, medical supplies, and diabetic supplies range from no coinsurance to 20% coinsurance; diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 013 FL (PPO) covers diagnostic and radiological services with prior authorization, offering lab services and outpatient X-rays with no copay. Outpatient diagnostic procedures and tests have a copay ranging from $0 to $95 with no coinsurance, while therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
DEVOTED CHOICE GIVEBACK 013 FL (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered under DEVOTED CHOICE GIVEBACK 013 FL (PPO) with no coinsurance and require prior authorization. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require copayments ranging from $20.00 to $30.00.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 013 FL (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance and requires no prior 3-day hospital stay, though prior authorization is required. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, while additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by DEVOTED CHOICE GIVEBACK 013 FL (PPO), which offers over-the-counter (OTC) items up to $120 every three months and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and other select services are not covered.
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