DEVOTED CHOICE GIVEBACK EXTRAS 011 NE (PPO) Medicare Advantage Plan H9802-011 • 2027
- Monthly Premium
- $0.00Plus Part B premium.
- Medical Deductible
- $150
- Maximum Out-of-Pocket
- $7250.00In-network
- Part B Giveback
- −$75.00 reduction
- Prescription Coverage
- Enhanced, $700.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- See List
- Total Enrollment
- 0 beneficiaries
DEVOTED CHOICE GIVEBACK EXTRAS 011 NE (PPO) Introduction
This Medicare Advantage PPO plan, DEVOTED CHOICE GIVEBACK EXTRAS 011 NE, is offered by Devoted Health and uses a Preferred Provider Organization (PPO) provider network. It comes with prescription drug coverage. For the 2027 plan year, the monthly premium is $0.00, the medical deductible is $150, and the in-network maximum out-of-pocket is $7250.00. The plan is identified by CMS Plan ID H9802-011. The 2027 Part D prescription drug deductible is $700.00.
Plan Benefits
Cost-sharing for DEVOTED CHOICE GIVEBACK EXTRAS 011 NE includes out-of-pocket expenses for covered healthcare services. The following tables provide a summary of typical in-network out-of-pocket costs for plan H9802-011.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | In-network: $0 copay Out-of-network: $5 copay |
Coming soon |
| Specialist | In-network: $50 copay Out-of-network: $50 copay |
Coming soon |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Telehealth benefit | In-network: $0-$50 copay | Coming soon |
| Routine chiropractic | Not covered | Coming soon |
| Fitness benefits | Coming soon | Coming soon |
| Health education | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Counseling services | Not covered | Coming soon |
| Over-the-counter drug benefits | In-network: $0 copay Out-of-network: 90% coinsurance |
Coming soon |
| Health transportation (non-emergency) | Coming soon | Coming soon |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | In-network: $25-$300 copay Out-of-network: $25-$300 copay |
Coming soon |
| Lab services | In-network: $0-$50 copay, 20% coinsurance Out-of-network: $0-$50 copay, 20% coinsurance |
Coming soon |
| Outpatient x-rays | In-network: $0-$75 copay Out-of-network: $0-$75 copay |
Coming soon |
| Diagnostic tests and procedures | In-network: $0-$95 copay Out-of-network: $0-$95 copay |
Coming soon |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | $115 copay | Coming soon |
| Worldwide emergency care | Coming soon | Coming soon |
| Urgent care | $0-$40 copay | Coming soon |
| Inpatient hospital care | In-network: Tier 1 $490 per day for days 1-5 $0 per day for days 6-90 $0 per stay Out-of-network: $490 per day for days 1-5 $0 per day for days 6-90 $0 per stay |
Coming soon |
| Skilled Nursing Facility | In-network: Tier 1 $0 per day for days 1-20 $221 per day for days 21-100 Out-of-network: 40% per stay |
Coming soon |
| Ground ambulance | In-network: $0-$345 copay Out-of-network: $0-$345 copay |
Coming soon |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | In-network: $50 copay Out-of-network: $50 copay |
Coming soon |
| Outpatient group therapy | In-network: $50 copay Out-of-network: $50 copay |
Coming soon |
| Inpatient psychiatric hospital care | In-network: Tier 1 $490 per day for days 1-5 $0 per day for days 6-90 $0 per stay Out-of-network: $490 per day for days 1-5 $0 per day for days 6-90 $0 per stay |
Coming soon |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | In-network: $50 copay Out-of-network: $50 copay |
Coming soon |
| Occupational therapy | In-network: $35 copay Out-of-network: $35 copay |
Coming soon |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | In-network: $0 copay Out-of-network: 50% coinsurance |
Coming soon |
| Durable medical equipment | In-network: 18% coinsurance Out-of-network: 45% coinsurance |
Coming soon |
| Prosthetics | In-network: 0%-18% coinsurance Out-of-network: 0%-35% coinsurance |
Coming soon |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | In-network: 0%-20% coinsurance Out-of-network: 40% coinsurance |
Coming soon |
| Other Part B drugs (Medicare-covered) | In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
Coming soon |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Dental x-rays | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Cleaning | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Periodontics | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
Coming soon |
| Endodontics | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
Coming soon |
| Restorative services | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
Coming soon |
| Implant services | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
Coming soon |
| Orthodontics | Not covered | Coming soon |
| Oral/Maxillofacial surgery | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
Coming soon |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Contact lenses | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Eyeglass frames only | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Eyeglass lenses only | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Eyeglasses (frames & lenses) | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Upgrades | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | In-network: $0 copay Out-of-network: $35 copay |
Coming soon |
| Fitting/evaluation | In-network: $0 copay Out-of-network: $35 copay |
Coming soon |
| Prescription hearing aids | In-network: $599-$899 copay Out-of-network: 90% coinsurance |
Coming soon |
| OTC hearing aids | Not covered | Coming soon |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Not covered | Coming soon |
| Home-based palliative care | Not covered | Coming soon |
| Personal emergency response system | Coming soon | Coming soon |
| Weight management programs | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Wigs for chemotherapy-related hair loss | Coming soon | Coming soon |
| Alternative therapies | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Massage therapy | Not covered | Coming soon |
| Home/bathroom safety devices | In-network: $0 copay Out-of-network: 45% coinsurance |
Coming soon |
Certain preventive services are covered 100% by DEVOTED CHOICE GIVEBACK EXTRAS 011 NE as a Part B benefit.
Prescription Drug Coverage
DEVOTED CHOICE GIVEBACK EXTRAS 011 NE 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 Advantage 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.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | ($4.20) |
| Supplemental Part D Premium: | $$4.20 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | $24.60 |
| Low-Income Premium Subsidy Paid by CMS: | $0.00 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $700.00 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 EXTRAS 011 NE may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | Coming soon |
| Generic | $1.00 copay | Coming soon |
| Preferred Brand | 25% coinsurance | Coming soon |
| Non-Preferred Drug | 25% coinsurance | Coming soon |
| Specialty Tier | 25% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H9802)
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.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | Plan too new to be measured |
| Managing Chronic (Long Term) Conditions | Plan too new to be measured |
| Member Experience with Health Plan | Plan too new to be measured |
| Complaints and Changes in Plans Performance | Plan too new to be measured |
| Health Plan Customer Service | Plan too new to be measured |
| Drug Plan Customer Service | Plan too new to be measured |
| Complaints and Changes in the Drug Plan | Plan too new to be measured |
| Member Experience with the Drug Plan | Plan too new to be measured |
| Drug Safety and Accuracy of Drug Pricing | Plan too new to be measured |
Contact Information for Devoted Health
- Website
- Devoted Health Plan Page
- Providers
- Devoted Health Providers Page
- Formulary
- Devoted Health Formulary Page
- Pharmacy
- Devoted Health Pharmacy Page
- New Member Health Plan Help
- (844)978-2770
- New Member Health Plan TTY
- 711
- New Member Part D Help
- (844)978-2770
- New Member Part D TTY Users
- 711
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Plan Availability
DEVOTED CHOICE GIVEBACK EXTRAS 011 NE (H9802-011-0) is available in the following locations:
Frequently Asked Questions
Here are some of the most frequently asked questions about this plan (click to open).
Frequently Asked Questions About DEVOTED CHOICE GIVEBACK EXTRAS 011 NE (PPO)
What is the monthly premium for DEVOTED CHOICE GIVEBACK EXTRAS 011 NE (PPO)?
The 2027 monthly premium is $0.00. The Medicare Part B premium is paid separately.
What is the in-network MOOP for plan H9802-011?
For 2027, the in-network maximum out-of-pocket is $7250.00. The plan pays 100% of covered in-network services beyond this amount.
What is the CMS star rating for this plan?
CMS rates this plan at ★0.0 out of 5 stars for 2027.
What is the total enrollment for plan H9802-011?
Total enrollment is 0 beneficiaries based on the latest CMS data.
What is the Part D deductible for plan H9802-011?
The plan’s Part D deductible is $700.00, applied to covered prescription drug costs.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Devoted Health (official source) | http://www.devoted.com | October 4, 2026 |
| CMS.gov | Medicare Advantage Plan Fact Sheet | 25 May, 2025 |
| AARP.org | The Big Choice: Original Medicare vs. Medicare Advantage | 25 May, 2025 |
| Medicare.gov | Your coverage options | 25 May, 2025 |
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