DEVOTED CHOICE GIVEBACK 005 TN (PPO) Medicare Advantage Plan H9231-005 • 2026 • Clay County, TN

DEVOTED CHOICE GIVEBACK 005 TN Overview

Coverage Overview for DEVOTED CHOICE GIVEBACK 005 TN

This MAPD PPO Medicare Advantage plan includes Medicare Part A and Part B services along with integrated prescription drug coverage. The monthly premium is $0.00, and the plan allows access to Medicare-approved providers, with lower costs when using in-network providers. The annual Part D deductible is $605.00.

Primary care visits have a $0 copay | Out-of-network: $5 copay, and specialist visits come with a $50 copay | Out-of-network: $50 copay. Urgent care services carry a $0-$40 copay, and ground ambulance transportation is $0-$350 copay | Out-of-network: $0-$350 copay. These costs apply toward the annual maximum out-of-pocket (MOOP) limit of $8300.00. After this limit is reached, in-network services are fully covered.

This plan is recognized by CMS under Plan ID H9231-005. Cost-sharing details are outlined below.

Out-of-Pocket Costs

DEVOTED CHOICE GIVEBACK 005 TN includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The table below outlines the most common in-network out-of-pocket costs associated with plan H9231-005.

Certain preventive services are covered 100% by DEVOTED CHOICE GIVEBACK 005 TN as a Part B benefit.

Prescription Drug Coverage

DEVOTED CHOICE GIVEBACK 005 TN 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 005 TN 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.