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DEVOTED CHOICE 004 HI (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE 004 HI (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED CHOICE 004 HI (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE 004 HI (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Honolulu, Kauai Counties. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that DEVOTED CHOICE 004 HI (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about DEVOTED CHOICE 004 HI (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For DEVOTED CHOICE 004 HI (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $370.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $10000.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $10000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The DEVOTED CHOICE 004 HI (PPO) Medicare plan features an annual drug deductible of $370. Under this plan, Tier 1 preferred generic drugs have no copay for 1-month, 2-month, or 3-month supplies through standard pharmacies and standard mail order. For Tier 2 generic drugs, standard pharmacy copays range from $1.00 to $3.00, while standard mail order copays range from $1.00 to $2.50 depending on the supply duration. For higher-tier medications, the plan transitions to coinsurance costs. Tier 3 preferred brand drugs require a 24% coinsurance, and Tier 4 non-preferred drugs require a 25% coinsurance at standard pharmacies and mail order services. Tier 5 specialty drugs have a 28% coinsurance for a 1-month supply.
Additional Benefits
The DEVOTED CHOICE 004 HI (PPO) plan offers comprehensive coverage with no copay for primary care visits, home health services, and essential preventive care like annual physicals. For hospital care, members pay a $375 daily copay for the first five days of inpatient stays, with no copay required for days 6 through 90. Emergency room visits feature a $130 copay, which is waived if you are admitted to the hospital within 24 hours. For extra health services, this plan features dental coverage up to a $1,500 annual maximum with no copay for preventive care, alongside a $200 annual eyewear allowance with no copay. Routine hearing exams require a $45 copay, while covered prescription hearing aids carry a copay between $399 and $699. Additionally, durable medical equipment is covered with no copay and a 19% coinsurance, and skilled nursing facility stays require no copay for the first 20 days.
Inpatient Hospital See details
DEVOTED CHOICE 004 HI (PPO) covers inpatient hospital services with no coinsurance, requiring a $375 daily copay for days 1 through 5 and no copay for days 6 through 90. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE 004 HI (PPO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services, and a $45 copay for outpatient substance abuse sessions. Outpatient hospital service copays range from $0 to $475, while outpatient observation services require a $375 copay per stay.
Partial Hospitalization See details
Partial hospitalization benefits are covered by DEVOTED CHOICE 004 HI (PPO) with a $60.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
DEVOTED CHOICE 004 HI (PPO) covers ambulance services with prior authorization, featuring a copay ranging from no copay up to $315 alongside coinsurance for ground transport, and a 20% coinsurance plus a copay for air transport. Transportation services are not covered under this plan, as trips to plan-approved or health-related locations are excluded.
Emergency Services See details
DEVOTED CHOICE 004 HI (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services range from no copay to a $45 copay with no coinsurance, while worldwide emergency services are covered up to $25,000 with a $130 copay for emergency or urgent care and a $315 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE 004 HI (PPO) offers primary care physician services with no copay and no coinsurance, while specialist, mental health, and physical therapy services require copays of $45 to $50 and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance for up to 12 routine visits per year, but other chiropractic services and podiatry services are not covered.
Preventive Services See details
DEVOTED CHOICE 004 HI (PPO) preventive services are partially covered, offering key benefits like annual physicals, kidney disease education, and diabetes training with no copay and no coinsurance. Additional benefits like fitness programs and nutritional counseling have no copay, though alternative therapies and therapeutic massages require a 0% to 50% coinsurance. Several services are not covered under this plan, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, caregiver support, and home-based palliative care.
Hearing Services See details
DEVOTED CHOICE 004 HI (PPO) offers partially covered hearing services, featuring routine hearing exams for a $45 copay and no coinsurance, and unlimited fitting evaluations. Covered prescription hearing aids require a copay of $399 to $699 and no coinsurance, but OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE 004 HI (PPO), featuring one annual routine eye exam with a copay ranging from no copay to $45 and no coinsurance, though other eye exam services are not covered. Covered eyewear has no copay and no coinsurance, providing up to a $200 annual maximum benefit for contacts, frames, and lenses.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE 004 HI (PPO) up to a $1,500 annual maximum, featuring no copay and no coinsurance for preventive care, and no copay with 0% to 50% coinsurance for most comprehensive services. Medicare-covered dental services require a $45 copay and no coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED CHOICE 004 HI (PPO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs have no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by the DEVOTED CHOICE 004 HI (PPO) plan with no copay and a 20% coinsurance, and prior authorization is required.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED CHOICE 004 HI (PPO) with no copays, though prior authorization is required. Covered durable medical equipment has a 19% coinsurance, prosthetic devices and medical supplies range from no coinsurance to 20% coinsurance, and diabetic supplies range from no coinsurance to 19% coinsurance, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CHOICE 004 HI (PPO), requiring prior authorization for all services. Diagnostic services have no coinsurance, featuring no copay for lab work and a $0 to $95 copay for procedures, while radiological services require a minimum 20% coinsurance for therapeutic treatments, copays starting at $0 for diagnostic radiology, and no copay for X-rays.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE 004 HI (PPO) plan with no copay and no coinsurance. Prior authorization is required to receive these services.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE 004 HI (PPO) covers Cardiac Rehabilitation Services with no coinsurance, and prior authorization is required. While some services are covered, specific programs including cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) rehabilitation are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE 004 HI (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior three-day hospital stay requirement, though prior authorization is required. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, with additional days not covered.
Other Services See details
DEVOTED CHOICE 004 HI (PPO) partially covers other services, offering acupuncture with no copay and 50% coinsurance, as well as over-the-counter items and additional preventive services with no copay and no coinsurance. Meal benefits are not covered under this plan.
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