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Devoted CHOICE GIVEBACK Hawaii (PPO)

H2686 - 009 - 0
3.5 out of 5 stars (3.5 / 5)

Devoted CHOICE GIVEBACK Hawaii (PPO) is a Medicare Advantage Plan by Devoted Health.

This page features plan details for 2025 Devoted CHOICE GIVEBACK Hawaii (PPO) H2686 – 009 – 0 available in Maui and Hawaii Counties.

Locations

Devoted CHOICE GIVEBACK Hawaii (PPO) is offered in the following locations.

Hawaii
Hawaii County, Hawaii
Maui County, Hawaii

Click to see more locations

Plan Overview

Devoted CHOICE GIVEBACK Hawaii (PPO) offers the following coverage and cost-sharing.

Insurer:Devoted Health
Health Plan Deductible:$0
MOOP:$10,000 In and Out-of-network
$8,300 In-network
Drugs Covered:Yes

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 $122.70.

Premium Reduction:$122.70

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
$185.00 $0.00 $0.00 $122.70 $
Please Note:
  • 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: $590.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

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 DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $590.00 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 $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, 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.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Endodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Periodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Restorative Services
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Fluoride Treatment
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Oral Exams
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Other Diagnostic Dental Services
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Other Preventive Dental Services
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: $0-300 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0-95 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $0-75 copay (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: $0-95 copay (Authorization Required)
  • Lab services
    • In-Network: $0-20 copay (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: $0-75 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $0-300 copay (Authorization Required)
  • Lab services
    • Out-of-Network: $0-20 copay or 20% coinsurance (Authorization Required)

Doctor visits

  • Primary
    • Out-of-Network: $25 copay per visit
  • Specialist
    • Out-of-Network: $25-55 copay per visit
  • Primary
    • In-Network: $0 copay
  • Specialist
    • In-Network: $55 copay per visit

Emergency care/Urgent care

  • Urgent care
    • $0-45 copay per visit (always covered)
  • Emergency
    • $110 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $55 copay
  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • Out-of-Network: $55 copay

Ground ambulance

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

Health plan deductible

    • $0

Hearing

  • Medicare-Covered Hearing Exam
    • In-Network: $55 copay
    • Out-of-Network: $55 copay
  • Fitting/evaluation
    • Out-of-Network: $0 copay
  • Hearing aids
    • Out-of-Network: $599-899 copay (Limits Apply)
  • Hearing aids OTC
    • Not covered
  • Fitting/evaluation
    • In-Network: $0 copay
  • Hearing aids
    • In-Network: $599-899 copay (Limits Apply)

Inpatient hospital coverage

    • Out-of-Network: $375 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
    • In-Network: $375 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $10,000 In and Out-of-network
      $8,300 In-network

Medical equipment/supplies

  • Diabetes supplies
    • Out-of-Network: 15% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 0-15% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 15% coinsurance per item (Authorization Required)
    • Out-of-Network: 15% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 15-40% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: $0 copay (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 20% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: $45 copay (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: $45 copay (Authorization Required)
  • Outpatient individual therapy visit
    • Out-of-Network: $45 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $45 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • Out-of-Network: $375 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $45 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: $45 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • In-Network: $375 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $45 copay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $45 copay (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $0-475 copay per visit (Authorization Required)
    • Out-of-Network: $0-475 copay per visit (Authorization Required)

Preventive care

    • Out-of-Network: $0 copay
    • In-Network: $0 copay

Rehabilitation services

  • Physical therapy and speech and language therapy visit
    • In-Network: $0-50 copay
    • Out-of-Network: $0-50 copay
  • Occupational therapy visit
    • Out-of-Network: $0-35 copay
    • In-Network: $0-35 copay

Skilled Nursing Facility

    • Out-of-Network: $20 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)
    • In-Network: $0 per day for days 1 through 20
      $170 per day for days 21 through 60
      $0 per day for days 61 through 100 (Authorization Required)

Transportation

    • Not covered

Vision

  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Not covered
  • Routine eye exam
    • Out-of-Network: $0 copay (Limits Apply)
  • Upgrades
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Upgrades
    • Out-of-Network: $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

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

Need more information on Devoted CHOICE GIVEBACK Hawaii (PPO)? See 2025 Devoted CHOICE GIVEBACK Hawaii (PPO) at MedicareAdvantageRX.com.

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Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

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