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DEVOTED CHOICE GIVEBACK 019 TN (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 019 TN (PPO) is a PPO plan offered by Devoted Health
Plan ID: H7028-019
HelpAdvisor Editorial Team analysis of data from the 2027 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 019 TN (PPO) - H7028-019 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 |
|---|---|
| Drug Deductible | $650 |
| Out of Pocket Max | In-Network: $8400 Out-of-Network: N/A |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $2100 |
| Primary Care Doctor Visit | Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $15 |
| Specialty Doctor Visit | Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $60 Cost share applies to wound care services and specialist services. |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $490 per day for days 1 to 5 $0 per day for days 6 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 per lifetime. Please see Evidence of Coverage for full benefit details. |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $115 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $115 Copayment for Worldwide Emergency Transportation $285 Maximum Plan Benefit of $25,000 per lifetime. Please see Evidence of Coverage for full benefit details. |
| Ambulance Transportation | Ground Ambulance: Copayment for Ground Ambulance Services $0 to $285 Cost share applies per trip. Min cost share for facility to facility transfers. Max cost share for all other ambulance services. Air Ambulance: Coinsurance for Air Ambulance Services $20% Prior Authorization Required for Air Ambulance Cost share applies per trip. |
Health Care Services and Medical Supplies
DEVOTED CHOICE GIVEBACK 019 TN (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 | Out-of-Network: Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $25 In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0
Dexcom Continuous Glucose Monitors (CGMs) and Supplies (Preferred): Copayment when obtained at a retail pharmacy $0 Coinsurance when obtained through a Durable Medical Equipment provider 17% Non-Preferred CGMs and Supplies: Coinsurance when obtained at a retail pharmacy 17%
Please see the Evidence of Coverage for full glucose monitor benefit information. |
| Durable Medical Equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 17% 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 $50 Coinsurance for Genetic Testing 20% Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services The min cost share applies to home sleep studies and other diagnostic tests at a PCP office or in the home. The mid cost share applies to EKGs/EEGs/ECGs at a PCP, specialist office, or freestanding facility and all other diagnostic tests at a specialist office or freestanding facility. The max cost share applies to EKGs/EEGs/ECGs and all other diagnostic tests at an outpatient hospital. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $25 to $300 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $75 |
| Home Health Care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental Health Inpatient Care | Out-of-Network: Psychiatric Hospital Services: $490 per day for days 1 to 5 $0 per day for days 6 to 90 |
| Mental Health Outpatient Care | Out-of-Network: Mental Health Services: Copayment for Medicare Covered Individual Sessions $60 Copayment for Medicare Covered Group Sessions $60 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $590 Prior Authorization Required for Outpatient Hospital Services The min cost share applies to diagnostic colonoscopies and screening colonoscopies that become diagnostic. The max cost share applies to all other outpatient hospital services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $490 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $490 Prior Authorization Required for Ambulatory Surgical Center Services The min cost share applies to diagnostic colonoscopies and screening colonoscopies that become diagnostic. The max cost share applies to all other ASC services. |
| Outpatient Substance Abuse Care | Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $60 Copayment for Medicare Covered Group Sessions $60 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 |
| Over-the-counter (OTC) Items | Over-the-Counter Items (OTC): $120 per quarter to use toward the purchase of eligible over-the-counter (OTC) items at participating locations. You get the most out of your OTC benefits when you shop at participating locations. If you purchase items at non-participating stores, you will be responsible for a 90% coinsurance. Please see Evidence of Coverage for full benefit details. |
| Podiatry Services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $50 Prior Authorization Required for Podiatry Services Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $60 |
| Skilled Nursing Facility Care | Out-of-Network: Skilled Nursing Facility Services: Coinsurance for Skilled Nursing Facility per Stay 40% |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | Out-of-Network: Medicare Covered Preventive Dental: Copayment for office visit $60 |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Medicare-Covered Vision Care: Copayment for Medicare-Covered Diagnostic Eye Exams $50 Copayment for Diabetic Retinopathy Exams $0 Prior authorization may be required. Routine Vision Care: Copayment for Routine Eye Exam $0
Eyewear: Up to $200 each year for eyeglasses and/or contacts You can visit any eyewear provider, in-network or out-of-network. Please see the Evidence of Coverage for full benefit details. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | Out-of-Network: Hearing Exams: Copayment for Medicare-covered Hearing Care $60 Copayment for Routine Hearing Exam $35
Hearing Aids: Coinsurance per aid 90%
|
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 | Preventive Care: Our plan covers many preventive services at no cost, including:
|
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