2027 Medicare Advantage plan
DEVOTED CHOICE GIVEBACK 002 DE (PPO): 2027 benefits and costs
Devoted Health PPO
CMS plan ID: H0413-002-0 · Plan year: 2027
DEVOTED CHOICE GIVEBACK 002 DE (PPO) is a 2027 Medicare Advantage plan offered by Devoted Health. It is listed in Delaware.
2027 plan costs at a glance
- Organization
- Devoted Health
- Plan organization
- DEVOTED HEALTH INSURANCE COMPANY OF DELAWARE
- Parent company
- Devoted Health, Inc.
- Plan type
- PPO
- Part C premium
- $0.00
- Part D premium
- $0.00
- Prescription drug coverage
- Yes
- 2027 CMS Star Rating
- Plan too new to be measured
- Standard monthly Medicare Part B premium
- $209.50 (estimated)
- Monthly Part B premium after plan reduction
- $49.60 (estimated)$209.50 standard premium less $159.90 plan reduction.
You must continue to pay your Medicare Part B premium.
- Annual medical deductible
- $50.00
Applies to out-of-network Medicare-covered services and certain in-network Medicare-covered services; out-of-network $0 preventive care is exempt.
- In-network medical maximum
- $9,850.00
- Combined in/out-of-network medical maximum
- $14,500.00
- Out-of-network medical maximum
- Not applicable
- Part B premium reduction
- $159.90
2027 benefit summary
Doctor visits and medical care
Plan-level deductibles may still apply when a service-specific deductible is listed as No.
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Primary care doctor | $0
| $5.00 copay
| |
| Specialist visit | $55.00 copay
| $55.00 copay
|
|
| Telehealth | $0.00 to $55.00 copay
| Not summarized. Check coverage with the plan. |
|
| Emergency care | $115.00 copay | Not summarized. Check coverage with the plan. | |
| Urgent care | $0.00 to $40.00 copay | Not summarized. Check coverage with the plan. | |
| Home health | $0
| 40% coinsurance
|
|
| Dialysis | 20% coinsurance
| 20% coinsurance
|
|
| Part B chemotherapy and radiation drugs | 0% to 20% coinsurance
| 40% coinsurance
|
|
| Other Part B drugs | 0% to 20% coinsurance
| 0% to 40% coinsurance
|
|
| Kidney disease education services | $0
| $0
|
|
| Medicare-covered chiropractic | $15.00 copay
| $15.00 copay
|
|
| Medicare-covered foot care | $55.00 copay
| $55.00 copay
|
|
| Other health professionals | $0.00 to $55.00 copay
| $0.00 to $55.00 copay
|
|
Hospital, outpatient surgery and observation care
Inpatient stays and skilled nursing care
| Care | Your share of the cost | What to know |
|---|---|---|
| Inpatient hospital stay | $0.00 copay per stay Days 1–4: $475.00 copay per day Days 5–90: $0.00 copay per day |
|
| Inpatient mental health care | $0.00 copay per stay Days 1–4: $475.00 copay per day Days 5–90: $0.00 copay per day |
|
| Skilled nursing facility | Days 1–20: $0.00 copay per day Days 21–100: $221.00 copay per day |
|
See plan documents for out-of-network hospital and skilled nursing costs.
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Outpatient hospital care | $0.00 to $525.00 copay
| $0.00 to $525.00 copay
| |
| Hospital observation services | $475.00 copay
| $475.00 copay
| |
| Ambulatory surgical center | $0.00 to $425.00 copay
| $0.00 to $425.00 copay
|
|
| Outpatient blood | $0
| $0
|
|
Tests, imaging and laboratory services
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Diagnostic procedures and tests | $0.00 to $95.00 copay
| $0.00 to $95.00 copay
|
|
| Laboratory services | $0.00 to $55.00 copay; 20% coinsurance
| $0.00 to $55.00 copay; 20% coinsurance
|
|
| Diagnostic radiology (CT, MRI) | $25.00 to $300.00 copay
| $25.00 to $300.00 copay
|
|
| Therapeutic radiology | 20% coinsurance
| 40% coinsurance
|
|
| X-rays | $0.00 to $75.00 copay
| $0.00 to $75.00 copay
|
|
Mental health and substance use treatment
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Partial hospitalization | $70.00 copay
| $70.00 copay
|
|
| Intensive outpatient program | $70.00 copay
| $70.00 copay
|
|
| Substance use treatment, individual sessions | $50.00 copay
| $55.00 copay
|
|
| Substance use treatment, group sessions | $50.00 copay
| $55.00 copay
|
|
| Opioid treatment program | $50.00 copay
| $55.00 copay
|
|
| Mental health, individual sessions | $50.00 copay
| $55.00 copay
|
|
| Mental health, group sessions | $50.00 copay
| $55.00 copay
|
|
| Psychiatry, individual sessions | $50.00 copay
| $55.00 copay
|
|
| Psychiatry, group sessions | $50.00 copay
| $55.00 copay
|
|
Therapy and rehabilitation
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Occupational therapy | $35.00 copay
| $35.00 copay
|
|
| Physical and speech therapy | $55.00 copay
| $55.00 copay
|
|
| Cardiac rehabilitation | $30.00 copay
| $30.00 copay
|
|
| Intensive cardiac rehabilitation | $30.00 copay
| $30.00 copay
|
|
| Pulmonary rehabilitation | $25.00 copay
| $25.00 copay
|
|
| Supervised exercise for peripheral artery disease | $20.00 copay
| $20.00 copay
|
|
Ambulance, medical equipment and supplies
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Ground ambulance | $0.00 to $335.00 copay
| $0.00 to $335.00 copay
|
|
| Air ambulance | 20% coinsurance
| 20% coinsurance
|
|
| Durable medical equipment | 15% coinsurance
| 45% coinsurance
|
|
| Prosthetic devices | 0% to 15% coinsurance
| 0% to 35% coinsurance
|
|
| Medical supplies | 0% to 15% coinsurance
| 0% to 35% coinsurance
|
|
| Diabetic supplies | $0
| 50% coinsurance
|
|
| Diabetic shoes and inserts | $0
| 50% coinsurance
|
|
| Diabetic monitors | 0% to 15% coinsurance
| 45% to 50% coinsurance
|
|
Dental benefits
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Medicare-covered dental | $55.00 copay | $55.00 copay
| |
| Oral examsAdditional plan benefit | $0 | $0
| |
| Dental X-raysAdditional plan benefit | $0 | $0
| |
| Dental cleaningAdditional plan benefit | $0 | $0
| |
| FluorideAdditional plan benefit | $0 | $0
| |
| Restorative dental careAdditional plan benefit | $0 | $0
| |
| Root canal treatment (endodontics)Additional plan benefit | $0 | $0
| |
| Gum treatment (periodontics)Additional plan benefit | $0 | $0
| |
| Removable dentures (prosthodontics)Additional plan benefit | $0 | $0
| |
| Dental implantsAdditional plan benefit | $0 | $0
| |
| Fixed dental restorations (prosthodontics)Additional plan benefit | $0 | $0
| |
| Oral surgeryAdditional plan benefit | $0 | $0
| |
| Other dental servicesAdditional plan benefit | $0 | $0
|
Additional network details
These costs apply to the listed service categories and networks.
| Service | Network | Your share of the cost | What to know |
|---|---|---|---|
| Diagnostic and preventive dental (category)Additional plan benefit | Out-of-network | Confirm with the plan (copay); Confirm with the plan (coinsurance) |
|
| Comprehensive dental (category)Additional plan benefit | Out-of-network | Confirm with the plan (copay); Confirm with the plan (coinsurance) |
|
Vision benefits
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Medicare-covered eye exams | $0.00 to $55.00 copay
| $0.00 to $55.00 copay
|
|
| Routine eye examsAdditional plan benefit | $0 | $0
|
|
| Medicare-covered eyewear | $0
| $0
|
|
| Contact lensesAdditional plan benefit | $0 | $0
|
|
| Eyeglasses, lenses and framesAdditional plan benefit | $0 | $0
|
|
| Eyeglass lensesAdditional plan benefit | $0 | $0
|
|
| Eyeglass framesAdditional plan benefit | $0 | $0
|
|
Additional network details
These costs apply to the listed service categories and networks.
| Service | Network | Your share of the cost | What to know |
|---|---|---|---|
| Eye exams (category)Additional plan benefit | Out-of-network | Confirm with the plan (copay); Confirm with the plan (coinsurance) |
|
| Eyewear (category)Additional plan benefit | Out-of-network | Confirm with the plan (copay); Confirm with the plan (coinsurance) |
|
| UpgradesAdditional plan benefit | Out-of-network | $0
|
Hearing benefits
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Medicare-covered hearing exams | $55.00 copay
| $55.00 copay
|
|
| Routine hearing examsAdditional plan benefit | $0 | $35.00 copay
|
|
| Hearing aid fitting and evaluationAdditional plan benefit | $0 | $35.00 copay
|
|
| Prescription hearing aids (all types)Additional plan benefit | $599.00 to $899.00 copay
| 90% coinsurance
|
|
Additional network details
These costs apply to the listed service categories and networks.
| Service | Network | Your share of the cost | What to know |
|---|---|---|---|
| Hearing exams (category)Additional plan benefit | Out-of-network | Confirm with the plan (copay); Confirm with the plan (coinsurance) |
|
| Prescription hearing aids (category)Additional plan benefit | Out-of-network | Confirm with the plan (copay); Confirm with the plan (coinsurance) |
|
Extra benefits
| Service | In-network | Out-of-network | What to know |
|---|---|---|---|
| Annual physical examAdditional plan benefit | $0
| $0
|
|
| Fitness benefitAdditional plan benefit | $0
| 0% to 90% coinsurance
|
|
Additional services and network costs
Additional network details
These costs apply to the listed service categories and networks.
| Service | Network | Your share of the cost | What to know |
|---|---|---|---|
| Medicare-covered preventive servicesMedicare-covered care | Out-of-network | $0
| |
| Health EducationAdditional plan benefit | Out-of-network | $0
|
|
| Nutritional/Dietary BenefitAdditional plan benefit | Out-of-network | $0
|
|
| Home and Bathroom Safety Devices and ModificationsAdditional plan benefit | Out-of-network | 45% coinsurance
|
|
| Weight Management ProgramsAdditional plan benefit | Out-of-network | $0
|
|
| Alternative TherapiesAdditional plan benefit | Out-of-network | $0
|
|
| Glaucoma ScreeningMedicare-covered care | Out-of-network | $0
| |
| Diabetes Self-Management TrainingMedicare-covered care | Out-of-network | $0
| |
| Digital Rectal ExamsMedicare-covered care | Out-of-network | $0
| |
| EKG after a Welcome to Medicare visitMedicare-covered care | Out-of-network | $0
| |
| Medicare Part B insulinMedicare-covered care | Out-of-network | 40% coinsurance
|
Allowances and optional benefits
Wellness Bucks
One shared limit covers the listed services, not a separate allowance for each service.
- Services sharing this allowance
- Health Education; Nutritional/Dietary Benefit; Fitness Benefit; Weight Management Programs; Alternative Therapies
- How benefits are provided
- Reimbursement
- Advance choice of benefits required
- No
- Shared benefit limit
- $150.00
- How often this limit applies
- Every year
- Shared limit on visits or trips
- No
Prescription drug coverage
Costs shown are for initial coverage.
Drug deductible exceptions: Tier 1; Tier 2 are exempt from the deductible.
Standard retail costs
On a small screen, scroll the table sideways to compare all fill lengths.
| Drug tier | 30 days | 60 days | 100 days |
|---|---|---|---|
| Tier 1Preferred Generic | $0.00 | $0.00 | $0.00 |
| Tier 2Generic | $0.00 | $0.00 | $0.00 |
| Tier 3Preferred Brand | 15% | 15% | 15% |
| Tier 4Non-Preferred Drug | 25% | 25% | 25% |
| Tier 5Specialty Tier | 26% | Not listed | Not listed |
Mail-order and other pharmacies
Out-of-network pricing: You pay the standard retail copay or coinsurance, plus any difference between the pharmacy’s billed charge and the amount the plan allows at a standard retail pharmacy.
Standard mail order costs
On a small screen, scroll the table sideways to compare all fill lengths.
| Drug tier | 30 days | 60 days | 100 days |
|---|---|---|---|
| Tier 1Preferred Generic | $0.00 | $0.00 | $0.00 |
| Tier 2Generic | $0.00 | $0.00 | $0.00 |
| Tier 3Preferred Brand | 15% | 15% | 15% |
| Tier 4Non-Preferred Drug | 25% | 25% | 25% |
| Tier 5Specialty Tier | 26% | Not listed | Not listed |
Long-term care pharmacy costs
| Drug tier | 31 days |
|---|---|
| Tier 1Preferred Generic | $0.00 |
| Tier 2Generic | $0.00 |
| Tier 3Preferred Brand | 15% |
| Tier 4Non-Preferred Drug | 25% |
| Tier 5Specialty Tier | 26% |
Out-of-network pharmacy costs
| Drug tier | 30 days |
|---|---|
| Tier 1Preferred Generic | $0.00 |
| Tier 2Generic | $0.00 |
| Tier 3Preferred Brand | 15% |
| Tier 4Non-Preferred Drug | 25% |
| Tier 5Specialty Tier | 26% |
Drug coverage rules and exceptions
Tier 1: Preferred Generic
- Drugs included in this tier
- Part D Drugs Only
- Longer fills available for every covered drug
- Yes
- Some longer-fill prescriptions require a one-month first fill
- No
Tier 2: Generic
- Drugs included in this tier
- Both Part D and Excluded Drugs
- Longer fills available for every covered drug
- Yes
- Some longer-fill prescriptions require a one-month first fill
- No
Tier 3: Preferred Brand
- Drugs included in this tier
- Part D Drugs Only
- Longer fills available for every covered drug
- Yes
- Some longer-fill prescriptions require a one-month first fill
- No
Tier 4: Non-Preferred Drug
- Drugs included in this tier
- Part D Drugs Only
- Longer fills available for every covered drug
- Yes
- Some longer-fill prescriptions require a one-month first fill
- No
Tier 5: Specialty Tier
- Drugs included in this tier
- Part D Drugs Only
- Initial-coverage prices also apply to drugs exempt from the deductible
- Yes
Special cost protections apply to covered insulin and recommended adult vaccines.
Where this plan is offered
CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.