DEVOTED CHOICE GIVEBACK 021 TN (PPO)
DEVOTED HEALTH INSURANCE COMPANY OF SOUTH CAROLINA INC · 2027 plan year
Plan ID H7028-021-000
Local PPO★ 4.5 CMS StarsNew for 2027
- MOOP (in-network)
- $8,700
- MOOP (combined)
- $14,800
- Monthly premium
- $0/mo
- Part C $0 + Part D $0
- Prescription drugs
- Included
Plan information
- Contract / Plan / Segment
- H7028-021-000
- Medical deductible
- $250
- Part D premium
- $0/mo (part of the monthly premium above)
- Part D deductible
- $650/yr
- Also owed
- Your Medicare Part B premium, paid separately
More DEVOTED HEALTH INSURANCE COMPANY OF SOUTH CAROLINA INC plans in TN
Benefits & cost sharing
Hospital
| Benefit | In-network |
|---|---|
| Worldwide Urgent Care Coverage | $115 |
| Inpatient Hospital — Acute | $450/day for days 1–5, $0 after |
| Inpatient Hospital — Additional Days (Acute) | No charge |
| Inpatient Hospital — Psychiatric | $450/day for days 1–4, $0 after |
Pharmacy
| Benefit | In-network |
|---|---|
| Part B Drugs | See plan details |
| Chemotherapy & Radiation Drugs (Part B) | 0%-20% coinsurance |
| Other Part B Drugs | 0%-20% coinsurance |
Mental Health
| Benefit | In-network |
|---|---|
| Supplemental Health Benefits | See plan details |
| Mental Health Specialty Services | See plan details |
| Mental Health — Individual Sessions | $50 |
| Mental Health — Group Sessions | $50 |
Other
| Benefit | In-network |
|---|---|
| Urgently Needed Services | $0-$40 |
| Dental — Comprehensive | See plan details |
| Hearing — Routine Exams | No charge |
| Hearing — Fitting & Evaluation for Hearing Aid | No charge |
| Hearing — Prescription Hearing Aids | See plan details |
| Hearing — Hearing Aids (All Types) | $599-$899 |
| Partial Hospitalization Program | $115 |
| Home Health Services | No charge |
| Prosthetics & Orthotics | See plan details |
| Worldwide Emergency & Urgent Coverage | See plan details |
| Worldwide Emergency Coverage | $115 |
| Intensive Outpatient Program (IOP) | $115 |
| Skilled Nursing Facility (SNF) | $0/day for days 1–20, $221/day for days 21–100 |
| Cardiac & Pulmonary Rehabilitation | See plan details |
| Cardiac Rehabilitation — Additional Sessions | $30 |
| Intensive Cardiac Rehabilitation — Additional Sessions | $30 |
| Pulmonary Rehabilitation — Additional Sessions | $25 |
| Supervised Exercise Therapy (SET) | $20 |
| Emergency Services | $115 |
| Worldwide Emergency Transportation | $275 copay + 20% coinsurance |
| Primary Care Physician Services | No charge |
| Chiropractic Services | $15 |
| Occupational Therapy Services | $35 |
| Physician Specialist Services | $50 |
| Podiatry Services | $50 |
| Other Health Care Professional Services | $0-$50 |
| Psychiatric Services | See plan details |
| Psychiatric Services — Individual Sessions | $50 |
| Psychiatric Services — Group Sessions | $50 |
| Physical Therapy & Speech-Language Pathology | $50 |
| Additional Telehealth Services (Part B) | $0-$50 |
| Opioid Treatment Program Services | $50 |
| Diagnostic Tests & Lab Services | See plan details |
| Diagnostic Procedures & Tests | $0-$95 |
| Laboratory Services | $0-$50 copay + 20% coinsurance |
| Radiological Services | See plan details |
| Diagnostic Radiology | $25-$300 |
| Therapeutic Radiology | 20% coinsurance |
| X-Ray Services | $0-$75 |
| Outpatient Hospital Services | $0-$550 |
| Hospital Observation Services | $450/day |
| Ambulatory Surgical Center (ASC) | $0-$450 |
| Outpatient Substance Abuse Services | See plan details |
| Substance Abuse — Individual Sessions | $50 |
| Substance Abuse — Group Sessions | $50 |
| Outpatient Blood Services | No charge |
| Ambulance Services | See plan details |
| Ground Ambulance | $0-$275 |
| Air Ambulance | 20% coinsurance |
| Durable Medical Equipment (DME) | 17% coinsurance |
| Prosthetic Devices | 0%-17% coinsurance |
| Medical Supplies | 0%-17% coinsurance |
| Diabetic Supplies & Services | See plan details |
| Diabetic Supplies | No charge |
| Diabetic Therapeutic Shoes & Inserts | No charge |
| Diabetic Monitors | 0%-17% coinsurance |
| Dialysis Services | 20% coinsurance |
| Over-the-Counter (OTC) Items | No charge |
| Other Supplemental Benefit | No charge |
| Glaucoma Screening | No charge |
| Other Supplemental Benefit | No charge |
| Medicare-Covered Preventive Services | See plan details |
| Annual Physical Exam | No charge |
| Health Education | No charge |
| Nutritional & Dietary Benefit | No charge |
| Fitness Benefit | No charge |
| Home & Bathroom Safety Devices | No charge |
| Weight Management Program | No charge |
| Alternative Therapies | No charge |
| Kidney Disease Education Services | No charge |
| Diabetes Self-Management Training | No charge |
| Digital Rectal Exams | No charge |
| Welcome to Medicare EKG | No charge |
| Insulin (Part B) | 0%-20% coinsurance (max $35) |
| Dental — Medicare-Covered Services | $50 |
| Dental — Preventive | See plan details |
| Dental — Oral Exams | No charge |
| Dental — X-Rays | No charge |
| Dental — Prophylaxis (Cleaning) | No charge |
| Dental — Fluoride Treatment | No charge |
| Dental — Restorative Services | No charge |
| Dental — Endodontics (Root Canal) | No charge |
| Dental — Periodontics (Gum Care) | No charge |
| Dental — Removable Prosthodontics (Dentures) | No charge |
| Dental — Implant Services | No charge |
| Dental — Fixed Prosthodontics (Bridges) | No charge |
| Dental — Oral & Maxillofacial Surgery | No charge |
| Dental — Adjunctive General Services | No charge |
| Vision — Eye Exams | $0-$50 |
| Vision — Eye Exams | See plan details |
| Vision — Routine Eye Exams | No charge |
| Vision — Eyewear | No charge |
| Vision — Eyewear | See plan details |
| Vision — Contact Lenses | No charge |
| Vision — Eyeglasses (Lenses & Frames) | No charge |
| Vision — Eyeglass Lenses | No charge |
| Vision — Eyeglass Frames | No charge |
| Vision — Eyewear Upgrades | No charge |
| Hearing — Exams | $50 |
| Hearing — Exams | See plan details |
Service area
- TN: 6 counties
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