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DEVOTED CHOICE GIVEBACK 002 OK (PPO)
The Centers for Medicare & Medicaid Services (CMS) publishes annual Star Ratings that reflect how each Medicare Advantage plan performs across a range of metrics, using a system of one to five stars.
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Monthly Premium
DEVOTED CHOICE GIVEBACK 002 OK (PPO) is a PPO plan offered by Devoted Health
Plan ID: H2845-002
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.
Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.
Learn more about Medicare Advantage plans such as DEVOTED CHOICE GIVEBACK 002 OK (PPO) - H2845-002 by Devoted Health as well as other Medicare Advantage plans available in your area.
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Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $605 |
| Out of Pocket Max |
In-Network: $9250 Out-of-Network: N/A |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $2100 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $55 Prior Authorization Required for Doctor Specialty Visit Cost share applies to wound care services, facet injections, cortisol injections, and specialist services. |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $475 per day for days 1 to 4 $0 per day for days 5 to 90 Prior Authorization Required for Acute Hospital Services |
| Urgent Care | Urgent Care: Copayment for Urgent Care $0 to $40 The min cost share applies to urgently needed services received by a PCP. The max cost share applies to urgently needed services received from an urgent care center. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $115 Maximum Plan Benefit of $25,000 |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $115 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $115 Copayment for Worldwide Emergency Transportation (Ground) $315 Maximum Plan Benefit of $25,000 |
| Ambulance Transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $0 to $315 Coinsurance for Medicare Covered Ambulance Services - Air $20% Cost share applies per trip. Min cost share for facility to facility transfers. Max cost share for all other ambulance services. |
Health Care Services and Medical Supplies
DEVOTED CHOICE GIVEBACK 002 OK (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services Out-of-Network: Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $15 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | Out-of-Network: Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 20% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 20% |
| Durable Medical Equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 15% Prior Authorization Required for Durable Medical Equipment |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $95 Copayment for Medicare-covered Lab Services $0 to $20 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Cost share varies based on site of service:PCPs office: No cost share for EKGs/EEGs/ECGs, no cost share all other. Specialist office: No cost share for EKGs/EEGs/ECGs, $40 copay all other. Freestanding facility: $40 copay for EKGs/EEGs/ECGs, $40 copay all other. Outpatient hospital: $95 copay for EKGs/EEGs/ECGs, $95 copay all other. No cost share for home sleep studies. No cost share for remote patient monitoring services. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $290 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $75 |
| Home Health Care | Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 40% |
| Mental Health Inpatient Care | Out-of-Network: Psychiatric Hospital Services: $475 per day for days 1 to 4 $0 per day for days 5 to 90 |
| Mental Health Outpatient Care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $50 Copayment for Medicare-covered Group Sessions $50 |
| Outpatient Services / Surgery | Out-of-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $475 Copayment for Medicare Covered Ambulatory Surgical Center Services $0 to $475 The min cost share applies to diagnostic colonoscopies, the max cost share applies to all other outpatient hospital services. |
| Outpatient Substance Abuse Care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $50 Copayment for Medicare-covered Group Sessions $50 Prior Authorization Required for Outpatient Substance Abuse Services Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $55 Copayment for Medicare Covered Group Sessions $55 |
| Over-the-counter (OTC) Items | |
| Podiatry Services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $55 Prior Authorization Required for Podiatry Services Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $55 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $218 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | Medicare Covered Preventive Dental: Copayment for Office Visit $55 Prior Authorization Required for Medicare Covered Preventive Dental Non-Medicare Covered Dental Services: This plan has a Dental Allowance: You have a $250 yearly allowance toward preventive and comprehensive dental. You can see any licensed dentist in the United States. You will pay the costs yourself at first and then submit a request for reimbursement to Devoted. Cosmetic procedures, dental implants, and/or elective procedures are not covered. Non-Medicare Covered Preventive Dental: Maximum dental allowance of $250 every year
Maximum dental allowance of $250 every year
|
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | Out-of-Network: Eye Exams Services: Copayment for Medicare Covered Eye Exams $0 to $20 Copayment for Medicare Covered Eyewear $0 The min cost share applies to diabetic retinopathy exams. The max cost share applies to other Medicare-covered eye exams. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | Out-of-Network: Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $55 |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The DEVOTED CHOICE GIVEBACK 002 OK (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $605 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $605 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $605 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $605 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|