DEVOTED CHOICE GIVEBACK 009 NC (PPO)

by Devoted Health

2026 Medicare Advantage plan available in North Carolina

Plan ID H9700-009-0

Additional coverage:

RxHearingVisionDental

Medicare Advantage PPO $0 premium

Monthly plan premium $0 / mo

Annual deductible $0 / yr

Max out-of-pocket · in-network $9,250 / yr

Drug deductible $605 / yr

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Plan Overview

DEVOTED CHOICE GIVEBACK 009 NC (PPO) is a Medicare Advantage Plan With Part D Prescription Drug Coverage, which is available in North Carolina and offered by the health insurance company Devoted Health. This plan's network type is PPO, which determines the in-network doctors who accept the plan and whether a referral is needed.

Plan Name DEVOTED CHOICE GIVEBACK 009 NC (PPO)

Insurance Carrier Devoted Health

Plan Type Medicare Advantage Plan With Part D Prescription Drug Coverage

Network Type PPO

Cost Summary

DEVOTED CHOICE GIVEBACK 009 NC (PPO) has a monthly premium cost of $0 per month, with an annual deductible of $0 and a maximum out-of-pocket cost sharing of $9,250. The most common costs people evaluate when choosing a plan are listed here; a full list of benefit costs is defined below.

Monthly Premium $0 / mo

Health portion of premium $0

Drug portion of premium $0

Annual Deductible $0 / yr

Max Out-of-Pocket · in-network $9,250 / yr

Primary doctor visit $0 copay

Specialist visit $55 copay

ER visit $115 copay

Ambulance $0-$315 copay

Additional Benefits and Coverage

DEVOTED CHOICE GIVEBACK 009 NC (PPO) is a Medicare Advantage plan which includes Medicare Part D prescription drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. DEVOTED CHOICE GIVEBACK 009 NC (PPO) includes coverage for hearing, vision, dental.

Part D Prescription Drug Coverage Yes

Dental Yes

Vision Yes

Hearing Yes

Nationwide Coverage No

Other benefits

Fitness benefit Limited coverage

Over-the-counter drug benefits Not covered

In-home support services Not covered

Home & bathroom safety devices Limited coverage

Meals for short duration Not covered

Annual physical exams Limited coverage

Telehealth Limited coverage

Medical Benefits

Doctor Services

Primary doctor visit In-network: $0 copay
Out-of-network: $5 copay

Specialist visit In-network: $55 copay
Out-of-network: $55 copay

Tests, labs & imaging

Diagnostic tests & procedures In-network: $0-$95 copay
Out-of-network: $0-$95 copay

Lab services In-network: $0-$40 copay
Out-of-network: $0-$40 copay

Diagnostic radiology services (like MRI) In-network: $0-$280 copay
Out-of-network: $0-$280 copay

Outpatient x-rays In-network: $0-$75 copay
Out-of-network: $0-$75 copay

Emergency care $115 copay

Urgent care $0-$40 copay

Hospital Services

Inpatient hospital coverage In-network:
  Tier 1
  $475 per day for days 1-4
  $0 per day for days 5-90
  $0 per stay
Out-of-network:
  $475 per day for days 1-4
  $0 per day for days 5-90
  $0 per stay

Outpatient hospital coverage In-network: $0-$475 copay
Out-of-network: $0-$475 copay

Skilled nursing facility

Skilled nursing facility In-network:
  Tier 1
  $0 per day for days 1-20
  $218 per day for days 21-100
Out-of-network:
  20% per stay

Preventive services

Preventive services In-network: $0 copay
Out-of-network: $0 copay

Ambulance

Ground ambulance In-network: $0-$315 copay
Out-of-network: $0-$315 copay

Therapy services

Occupational therapy visit In-network: $35 copay
Out-of-network: $35 copay

Physical therapy & speech & language therapy visit In-network: $55 copay
Out-of-network: $55 copay

Mental health services

Outpatient group therapy with a psychiatrist In-network: $50 copay
Out-of-network: $55 copay

Outpatient individual therapy with a psychiatrist In-network: $50 copay
Out-of-network: $55 copay

Outpatient group therapy visit In-network: $50 copay
Out-of-network: $55 copay

Outpatient individual therapy visit In-network: $50 copay
Out-of-network: $55 copay

Opioid treatment services

Opioid treatment services Covered

Other services

Durable medical equipment (like wheelchairs & oxygen) In-network: 16% coinsurance
Out-of-network: 20% coinsurance

Prosthetics (like braces, artificial limbs) In-network: 0%-20% coinsurance
Out-of-network: 0%-40% coinsurance

Diabetes supplies In-network: 0%-16% coinsurance
Out-of-network: 20% coinsurance

Prescription drugs (Part D benefits)

Drug tier standard retail · 1-month supply Initial coverage Catastrophic

Preferred Generic $0.00 copay $0 copay

Generic $3.00 copay $0 copay

Preferred Brand 21% coinsurance $0 copay

Non-Preferred Drug 25% coinsurance $0 copay

Specialty Tier 25% coinsurance $0 copay

Part B drugs

Chemotherapy drugs In-network: 0%-20% coinsurance
Out-of-network: 40% coinsurance

Other Part B drugs In-network: 0%-20% coinsurance
Out-of-network: 0%-40% coinsurance

Extra Benefits

Hearing

Hearing exam In-network: $0 copay
Out-of-network: $0 copay

Fitting/evaluation In-network: $0 copay
Out-of-network: $0 copay

Hearing aids - prescription In-network: $599-$899 copay
Out-of-network: $599-$899 copay

Hearing aids - over the counter Not covered

Preventive dental

Oral exam In-network: $0 copay
Out-of-network: $0 copay

Cleaning In-network: $0 copay
Out-of-network: $0 copay

Fluoride treatment In-network: $0 copay
Out-of-network: $0 copay

Dental x-rays In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Restorative services In-network: $0 copay
Out-of-network: $0 copay

Endodontics In-network: $0 copay
Out-of-network: $0 copay

Periodontics In-network: $0 copay
Out-of-network: $0 copay

Prosthodontics, removable In-network: $0 copay
Out-of-network: $0 copay

Prosthodontics, fixed In-network: $0 copay
Out-of-network: $0 copay

Maxillofacial prosthetics Not covered

Implant services Not covered

Oral and maxillofacial surgery In-network: $0 copay
Out-of-network: $0 copay

Orthodontics Not covered

Adjunctive general services In-network: $0 copay
Out-of-network: $0 copay

Vision

Routine eye exam In-network: $0 copay
Out-of-network: $0 copay

Contact lenses In-network: $0 copay
Out-of-network: $0 copay

Eyeglasses (frames & lenses) In-network: $0 copay
Out-of-network: $0 copay

Eyeglass frames (only) In-network: $0 copay
Out-of-network: $0 copay

Eyeglass lenses (only) In-network: $0 copay
Out-of-network: $0 copay

Upgrades In-network: $0 copay
Out-of-network: $0 copay

Plan documents & tools

Plan details (carrier site)Provider directory Drug list (formulary)

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