Devoted CHOICE GIVEBACK Hawaii (PPO)
H2686 - 003 - 0
(0 / 5)
Devoted CHOICE GIVEBACK Hawaii (PPO) is a Medicare Advantage Plan by Devoted Health.
This page features plan details for 2024 Devoted CHOICE GIVEBACK Hawaii (PPO) H2686 – 003 – 0 available in Honolulu and Kauai.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
No 2025 version found. You can use the location links below to find 2025 plans in your area.
Locations
Devoted CHOICE GIVEBACK Hawaii (PPO) is offered in the following locations.
Plan Overview
Devoted CHOICE GIVEBACK Hawaii (PPO) offers the following coverage and cost-sharing.
| Insurer: | Devoted Health |
| Health Plan Deductible: | $0.00 |
| MOOP: | $10,000 In and Out-of-network $8,300 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $545 annual deductible only applies to drugs on certain tiers.
Ready to sign up for Devoted CHOICE GIVEBACK Hawaii (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Devoted CHOICE GIVEBACK Hawaii (PPO) qualifies for a monthly Medicare Give Back Benefit of $105.00.
| Premium Reduction: | $105.00 |
Premium Breakdown
Devoted CHOICE GIVEBACK Hawaii (PPO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $105.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Devoted CHOICE GIVEBACK Hawaii (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $545.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.
The table below shows how the LIS impacts the Part D premium of this plan.
| Part D | LIS Full |
|---|---|
| $0.00 | $ |
Initial Coverage Phase
After you pay your $545.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $5.00 copay | $5.00 copay | ||
| 3 (Preferred Brand) | $47.00 copay | $47.00 copay | ||
| 4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay | ||
| 5 (Specialty Tier) | 25% | 25% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $15.00 copay | $12.50 copay | ||
| 3 (Preferred Brand) | $141.00 copay | $117.50 copay | ||
| 4 (Non-Preferred Drug) | $300.00 copay | $300.00 copay | ||
| 5 (Specialty Tier) |
Gap Coverage Phase
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) * | $0.00 copay | $0.00 copay | ||
| 2 (Generic) * | $5.00 copay | $5.00 copay | ||
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) * | $0.00 copay | $0.00 copay | ||
| 2 (Generic) * | $15.00 copay | $12.50 copay | ||
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.
Additional Benefits
Devoted CHOICE GIVEBACK Hawaii (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $10,000 In and Out-of-network $8,300 In-network |
| No |
| In-network | No |
| In-network | $0-400 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | $0-400 copay per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| In-network Specialist | $50 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $50 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0-55 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0-100 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | $0-100 copay (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $0-250 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | $0-250 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $0-100 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | $0-100 copay (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $50 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $50 copay (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $399-699 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $399-699 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | 0-50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | 0-50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fluoride treatment | 0-50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | 0-50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic services | 0-50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Restorative services | 0-50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Periodontics | 0-50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Extractions | 0-50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Occupational therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| In-network | $295 copay (Not applicable.) (Not applicable.) |
| out-of-network | $295 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $50 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $50 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 0-35% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 40% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | 40% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 25% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 25% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 25% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $475 per day for days 1 through 4 $0 per day for days 5 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network | $475 per day for days 1 through 4 $0 per day for days 5 through 90 (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $475 per day for days 1 through 4 $0 per day for days 5 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $475 per day for days 1 through 4 $0 per day for days 5 through 90 (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $45 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $45 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $45 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $45 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $45 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $45 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $45 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $45 copay (Authorization is required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $200 per day for days 21 through 61 $0 per day for days 62 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | 40% per stay (Authorization is required.) (Referral is not required.) |
Ready to sign up for Devoted CHOICE GIVEBACK Hawaii (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Table of Contents
Need more information on Devoted CHOICE GIVEBACK Hawaii (PPO)? See 2025 Devoted CHOICE GIVEBACK Hawaii (PPO) at MedicareAdvantageRX.com.
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SMID: MULTIPLAN_HCIHNDOGMED01PY25_M
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