DEVOTED CHOICE GIVEBACK 011 PA (PPO) Medicare Advantage Plan H6018-011 • 2026 • Jefferson County, PA

DEVOTED CHOICE GIVEBACK 011 PA Overview

Plan Overview for DEVOTED CHOICE GIVEBACK 011 PA

This Medicare Advantage MAPD PPO plan combines hospital, medical, and prescription drug coverage and allows access to Medicare-approved providers. The monthly premium is $0.00, and the plan includes Medicare Part A and Part B benefits along with integrated prescription drug coverage. The annual Part D deductible is $605.00.

Primary care visits have a $0 copay | Out-of-network: $5 copay, while specialist visits come with a $45 copay | Out-of-network: $45 copay. Urgent care services carry a $0-$40 copay, and ground ambulance transportation is $0-$375 copay | Out-of-network: $0-$375 copay. These costs apply toward the annual maximum out-of-pocket (MOOP) limit of $9250.00. After this limit is reached, in-network services are fully covered for the remainder of the year.

This plan is listed by CMS under Plan ID H6018-011. Cost-sharing details for key services are provided below.

Cost-Sharing Overview

Cost-sharing for DEVOTED CHOICE GIVEBACK 011 PA includes out-of-pocket expenses for covered healthcare services. The table below provides a summary of typical in-network out-of-pocket costs for plan H6018-011.

Certain preventive services are covered 100% by DEVOTED CHOICE GIVEBACK 011 PA as a Part B benefit.

Prescription Drug Coverage

DEVOTED CHOICE GIVEBACK 011 PA includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.

This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.

Prescription Drug Plan Premium

The Part D prescription drug plan premium is included in the overall Medicare Special Needs Plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.

For more details, visit the Social Security Extra Help program .

Prescription Drug Plan Deductible

This plan has a $605.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Devoted Health starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, DEVOTED CHOICE GIVEBACK 011 PA may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

CMS 5-Star Ratings

CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.