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Devoted Health, Inc.

Plan ID: H9231-1-0

Devoted CHOICE Tennessee (PPO)

2025 Devoted CHOICE Tennessee (PPO) H9231 — 001 — 0 is a Medicare Advantage plan with drug coverage. 0

Learn more about Devoted CHOICE Tennessee (PPO) H9231 - 001 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

0

$0.00 /mo

Monthly premium

$590.00

Drug deductible

$6400.00

Out-of-pocket maximum

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Call to enroll

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Get personalized help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!

OverviewBenefits & CostsDrug CoverageAdditional Benefits
Overview Icon

Plan Overview

2025 Devoted CHOICE Tennessee (PPO) H9231 — 001 — 0 is a PPO offered in by Devoted Health, Inc.. It has a monthly premium of $0.00.

Premium Breakdown

Standard Part B Premium

$185.00

Part B premium reduction

- $0

Monthly Plan Premium

$0.00

Total Premium:

$185.00

Note:

The standard Medicare Part B premium for 2025 is $185.00. Your premium may differ based on factors like late enrollment, income (IRMAA), or disability status. Most people enrolled in Medicare Part B are required to pay this premium.

Special needs plan type

No

Out-of-pocket maximum

$6400.00

Plan Organization:

Devoted Health, Inc.

Plan Type:

PPO

Location:

Drugs Covered:

Yes

Drug Formulary:

Not yet released

Pharmacies:

Not yet released

Doctor Choice:

Doctors Link:

Not yet released

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Drug deductible

$590

Note:

This plan does not charge an annual deductible for all drugs. The $590.00 annual deductible only applies to drugs in certain tiers.

Sign up for Devoted CHOICE Tennessee (PPO)

Enroll online

Call to enroll

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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 Icon

Drug Coverage

Devoted CHOICE Tennessee (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Benefit Type

Enhanced Alternative

Prescription drug deductible

$590.00

Part D Premium Reduction

This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.

Part D

LIS Full

$0.00

$0.00

Initial Coverage Phase

After you pay your $590.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2000.00. Once you reach that amount, you will enter the next coverage phase.

30 Days
60 Days
90 Days

Tier

Preferred Pharmacy

Standard Pharmacy

Preferred Mail

Standard Mail

1. Preferred Generic

-

-

-

-

2. Standard Generic

-

-

-

-

3. Preferred Brand

-

-

-

-

4. Non-Preferred Drug

-

-

-

-

5. Specialty Tier

-

-

-

-

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.

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Additional Benefits

Devoted CHOICE Tennessee (PPO) also provides the following benefits.

Note:

Limits, Authorizations, and Referrals may apply for the benefits below. Contact the plan for details.

Additional Coverage Icon

Comprehensive dental

Adjunctive General Services
In-Network: No Coins - No Co pay
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Out-Of-Network: No Coins - No Copay
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Endodontics
In-Network: No Coins - No Co pay
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Out-Of-Network: No Coins - No Copay
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Oral and Maxillofacial Surgery
In-Network: No Coins - No Co pay
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Out-Of-Network: No Coins - No Copay
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Periodontics
In-Network: No Coins - No Co pay
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Out-Of-Network: No Coins - No Copay
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Prosthodontics, fixed
In-Network: No Coins - No Co pay
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Out-Of-Network: No Coins - No Copay
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Prosthodontics, removable
In-Network: No Coins - No Co pay
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Out-Of-Network: No Coins - No Copay
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Restorative Services
In-Network: No Coins - No Co pay
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Out-Of-Network: No Coins - No Copay
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Preventive dental

Dental X-Rays
In-Network: No Coins - No Copay
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Out-Of-Network: No Coins - No Copay
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Fluoride Treatment
In-Network: No Coins - No Copay
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Out-Of-Network: No Coins - No Copay
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Oral Exams
In-Network: No Coins - No Copay
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Out-Of-Network: No Coins - No Copay
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Other Diagnostic Dental Services
In-Network: No Coins - No Copay
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Out-Of-Network: No Coins - No Copay
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Other Preventive Dental Services
In-Network: No Coins - No Copay
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Out-Of-Network: No Coins - No Copay
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Prophylaxis (cleaning)
In-Network: No Coins - No Copay
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Out-Of-Network: No Coins - No Copay
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Additional Coverage Icon

Diagnostic procedures/lab services/imaging

Diagnostic radiology services
Diagnostic tests and procedures
In-Network: $0-95 copay
Limit IconExclamation Icon
Out-Of-Network: $0-95 copay
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Lab services
In-Network: $0-20 copay
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Out-Of-Network: $0-20 copay or 20% coinsurance
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Outpatient x-rays
In-Network: $0-75 copay
Limit IconExclamation Icon
Out-Of-Network: $0-75 copay
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Additional Coverage Icon

Doctor visits

Primary
In-Network: $0 copay
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Out-Of-Network: $0 copay
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Specialist
In-Network: $0-40 copay per visit
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Out-Of-Network: $0-40 copay per visit
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Additional Coverage Icon

Emergency care/Urgent care

Urgent care
$0-45 copay per visit (always covered)
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Emergency
$125 copay per visit (always covered)
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Additional Coverage Icon

Foot care (podiatry services)

Routine foot care
Not covered
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Foot exams and treatment
In-Network: $40 copay
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Out-Of-Network: $40 copay
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Additional Coverage Icon

Ground ambulance

All service types
In-Network: $0-300 copay
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Out-Of-Network: $0-300 copay or 20% coinsurance
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Additional Coverage Icon

Hearing

Fitting/evaluation
In-Network: $0 copay
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Out-Of-Network: $0 copay
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Hearing aids OTC
Not covered
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Medicare-Covered Hearing Exam
In-Network: $30 copay
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Out-Of-Network: $30 copay
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Hearing aids
In-Network: $399-699 copay
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Out-Of-Network: $399-699 copay
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Additional Coverage Icon

Inpatient hospital coverage

All service types
In-Network: $325 per day for days 1 through 5 $0 per day for days 6 through 90
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Out-Of-Network: $325 per day for days 1 through 5 $0 per day for days 6 through 90
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Additional Coverage Icon

Outpatient hospital coverage

All service types
In-Network: $0-425 copay per visit
Limit IconExclamation Icon
Out-Of-Network: $0-425 copay per visit
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Optional benefits

All service types
No
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Additional Coverage Icon

Medical equipment/supplies

Durable medical equipment
Prosthetics
Diabetes supplies
In-Network: $0 copay
Limit IconExclamation Icon
Out-Of-Network: 40% coinsurance per item
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Medicare Part B drugs

Other Part B drugs
In-Network: 0-20% coinsurance
Limit IconExclamation Icon
Out-Of-Network: 40% coinsurance
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Chemotherapy
In-Network: 0-20% coinsurance
Limit IconExclamation Icon
Out-Of-Network: 40% coinsurance
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Additional Coverage Icon

Mental health services

Outpatient group therapy visit with a psychiatrist
In-Network: $40 copay
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Out-Of-Network: $40 copay
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Outpatient individual therapy visit
In-Network: $40 copay
Limit IconExclamation Icon
Out-Of-Network: $40 copay
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Outpatient group therapy visit
In-Network: $40 copay
Limit IconExclamation Icon
Out-Of-Network: $40 copay
Limit IconExclamation Icon
Outpatient individual therapy visit with a psychiatrist
In-Network: $40 copay
Limit IconExclamation Icon
Out-Of-Network: $40 copay
Limit IconExclamation Icon
Inpatient hospital - psychiatric
In-Network: $325 per day for days 1 through 5 $0 per day for days 6 through 90
Limit IconExclamation Icon
Out-Of-Network: $325 per day for days 1 through 5 $0 per day for days 6 through 90
Limit IconExclamation Icon
Additional Coverage Icon

Preventive care

All service types
In-Network: $0 copay
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Out-Of-Network: $0 copay
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Additional Coverage Icon

Rehabilitation services

Physical therapy and speech and language therapy visit
In-Network: $0-50 copay
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Out-Of-Network: $0-50 copay
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Occupational therapy visit
In-Network: $0-45 copay
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Out-Of-Network: $0-45 copay
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Additional Coverage Icon

Skilled Nursing Facility

All service types
In-Network: $0 per day for days 1 through 20 $214 per day for days 21 through 100
Limit IconExclamation Icon
Out-Of-Network: 40% per stay
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Transportation

All service types
Not covered
Limit Icon
Additional Coverage Icon

Vision

Eyeglass frames
In-Network: $0 copay
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Out-Of-Network: $0 copay
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Routine eye exam
In-Network: $0 copay
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Out-Of-Network: $0 copay
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Contact lenses
In-Network: $0 copay
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Out-Of-Network: $0 copay
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Eyeglass lenses
In-Network: $0 copay
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Out-Of-Network: $0 copay
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Upgrades
In-Network: $0 copay
Limit Icon
Out-Of-Network: $0 copay
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Eyeglasses (frames and lenses)
In-Network: $0 copay
Limit Icon
Out-Of-Network: $0 copay
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Other
Not covered
Limit Icon
Additional Coverage Icon

Wellness programs (eg, fitness, nursing hotline)

All service types
Covered
Limit Icon
Overview Icon

Plan Providers

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.

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Get Personalized Help from a licensed insurance agent

1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

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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.

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