Devoted CHOICE GIVEBACK Pennsylvania (PPO)

Pennsylvania Medicare Advantage Plan (2025 Plan)

Monthly Premium

Your Cost

by Devoted Health

Additional Coverage

HearingVisionDental

Overall Government Star Rating

(coming soon)

Ready to Enroll Online?

Plan Name

Devoted CHOICE GIVEBACK Pennsylvania (PPO)

Insurance Carrier

Devoted Health

Plan Type

Medicare Advantage Plan With Part D Prescription Drug Coverage

Network Type

PPO

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

Monthly Premium

Annual Deductible

Max Out-of-Pocket

$9,350

Primary doctor visit

$0 copay

Specialist visit

$45 copay per visit

ER visit

$110 copay per visit (always covered)

Ambulance

$0-350 copay

Devoted CHOICE GIVEBACK Pennsylvania (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 $14,000 In and Out-of-network $9,350 In-network. The most common benefit costs which people evaluate when choosing a plan are costs for a primary doctor visit, specialist doctor visit, emergency room visit, and ambulance. These costs are listed in this summary section and a full list of benefit costs for Devoted CHOICE GIVEBACK Pennsylvania (PPO) are defined below.

Yes

Part D Prescription Drug Coverage

Yes

Dental

Yes

Vision

Yes

Hearing

Devoted CHOICE GIVEBACK Pennsylvania (PPO) is a Medicare Advantage plan which does include Medicare Part D Prescription Drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. Devoted CHOICE GIVEBACK Pennsylvania (PPO) includes coverage for hearing, vision, dental.

Medicare Advantage health plans can offer even more additional benefits. Devoted CHOICE GIVEBACK Pennsylvania (PPO) includes coverage for the following additional benefits:

Other benefits

Fitness benefit

Limited coverage

Over the counter drug benefits

Not covered

In-home support services

Not covered

Home and bathroom safety devices

Limited coverage

Meals for short duration

Not covered

Annual physical exams

Limited coverage

Telehealth

Limited coverage

Monthly Premium

Health Portion of Premium

Drug Portion of Premium

Health Plan Deductible

Health Plan Max Out-of-Pocket

$14,000 In and Out-of-network
$9,350 In-network

Nationwide Coverage included

Hearing Coverage included

Yes

Vision Coverage included

Yes

Dental Coverage included

Yes

Doctor Lookup Link

http://www.Devoted.com

Plan Link

http://www.Devoted.com

Doctor Services

Primary doctor visit

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

Specialist visit

In-network: $45 copay per visit
Out-of-network: $0-45 copay per visit

Tests, labs, & imaging

Diagnostic tests & procedures

In-network: $0-95 copay
Out-of-network: $0-95 copay

Lab services

In-network: $0-55 copay
Out-of-network: $0-55 copay or 20% coinsurance

Diagnostic radiology services (like MRI)

In-network: $0-300 copay
Out-of-network: $0-300 copay

Outpatient x-rays

In-network: $0-75 copay
Out-of-network: $0-75 copay

Emergency care

$110 copay per visit (always covered)

Urgent care

$0-45 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage

In-network: $425 per day for days 1 through 4
$0 per day for days 5 through 90
Out-of-network: $425 per day for days 1 through 4
$0 per day for days 5 through 90

Outpatient hospital coverage

In-network: $0-575 copay per visit
Out-of-network: $0-575 copay per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$214 per day for days 21 through 60
$0 per day for days 61 through 100
Out-of-network: $20 per day for days 1 through 20
$214 per day for days 21 through 100

Preventive services

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

Ambulance

Ground ambulance

In-network: $0-350 copay
Out-of-network: $0-350 copay or 20% coinsurance

Therapy services

Occupational therapy visit

In-network: $35 copay
Out-of-network: $35 copay

Physical therapy & speech & language therapy visit

In-network: $45-50 copay
Out-of-network: $45-50 copay

Mental health services

Outpatient group therapy with a psychiatrist

In-network: $45 copay
Out-of-network: $45 copay

Outpatient individual therapy with a psychiatrist

In-network: $45 copay
Out-of-network: $45 copay

Outpatient group therapy visit

In-network: $45 copay
Out-of-network: $45 copay

Outpatient individual therapy visit

In-network: $45 copay
Out-of-network: $45 copay

Opioid treatment services

Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)

In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item

Prosthetics (like braces, artificial limbs)

In-network: 0-20% coinsurance per item
Out-of-network: 20-40% coinsurance per item

Diabetes supplies

In-network: $0 copay
Out-of-network: 20% coinsurance per item

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

Tiers	Initial coverage phase	Catastrophic coverage phase
Preferred Generic	$0.00 copay	$0 copay
Generic	$5.00 copay	$0 copay
Preferred Brand	25% 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: 35% coinsurance

Other Part B drugs

In-network: 0-20% coinsurance
Out-of-network: 35% coinsurance

Hearing

Hearing exam

In-network: $45 copay
Out-of-network: $45 copay

Fitting/evaluation

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

Hearing aids - All types

In-network: $599-899 copay
Out-of-network: $599-899 copay

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

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Devoted CHOICE GIVEBACK Pennsylvania (PPO)

Monthly Premium

Additional Coverage

Overall Government Star Rating

Ready to Enroll Online?

Plan Overview

Cost Summary

Additional Benefits and Coverage

Other benefits

Plan Benefits and Coverage Details

Medical Benefits

Doctor Services

Tests, labs, & imaging

Hospital Services

Skilled nursing facility

Preventive services

Ambulance

Therapy services

Mental health services

Opioid treatment services

Other services

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

Part B Drugs

Extra Benefits

Hearing

Preventive Dental

Comprehensive dental

Vision

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