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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.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
DEVOTED CHOICE 004 HI (PPO) is a PPO plan offered by Devoted Health Insurance Company of Hawaii Inc available for the 2026 plan year 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 that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6700.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $6700.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $10000.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $10000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
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 prescription drug deductible of $370. Under this plan, you will pay no copay for Tier 1 preferred generic drugs filled at standard pharmacies or through standard mail order. For Tier 2 generic drugs, copays are highly affordable, starting at $1.00 for a one-month supply and reaching a maximum of $3.00 for a three-month supply. Higher-tier medications are covered through coinsurance for both standard retail pharmacies and mail-order services. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs carry a 25% coinsurance. Specialty medications in Tier 5 are available with a 28% coinsurance for a one-month supply.
Additional Benefits
The DEVOTED CHOICE 004 HI (PPO) plan offers comprehensive medical coverage with no copays and no coinsurance for primary care doctor visits, annual physicals, and home health services. For inpatient hospital stays, members pay no coinsurance and no copay after day five, though a $375 daily copay applies for the first five days. Emergency room visits require a $130 copay, which is waived if admitted, while specialist visits and outpatient observation stays require copays of $50 and $375 respectively. This plan also includes valuable supplemental benefits, featuring no copays or coinsurance for preventive dental care up to a $1,500 annual limit and no copays for eyewear up to a $200 yearly allowance. Diagnostic lab services and outpatient X-rays are covered with no copay, while durable medical equipment and Part B drugs generally carry coinsurance up to 50% and 20% respectively. Additionally, routine hearing exams require a $50 copay, and prescription hearing aids are covered with copays ranging from $399 to $699.
Inpatient Hospital See details
DEVOTED CHOICE 004 HI (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $375 daily copay for days 1 through 5 and no copay for days 6 through 90. Prior authorization is required, and select services such as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE 004 HI (PPO) outpatient services are covered with no coinsurance, offering no copays for ambulatory surgical center and blood services. Outpatient hospital services require a copay ranging from $0 to $475, while observation services have a $375 copay per stay and outpatient substance abuse sessions have a $50 copay.
Partial Hospitalization See details
DEVOTED CHOICE 004 HI (PPO) covers partial hospitalization services with a $60.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE 004 HI (PPO) covers ground ambulance services with a copay ranging from no copay to $315 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, both requiring prior authorization. Transportation services to health-related locations are not covered under this plan.
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 up to a $50 copay with no coinsurance, and worldwide emergency services are covered up to a $25,000 maximum with copays up to $315 and 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 visits, therapy, psychiatric, and mental health services require a $50 copay and no coinsurance. Routine chiropractic care is covered for up to 12 visits per year with a $15 copay and no coinsurance, but other chiropractic services and podiatry services are not covered.
Preventive Services See details
DEVOTED CHOICE 004 HI (PPO) offers partially covered preventive services with no copay and no coinsurance for annual physicals, kidney disease education, and fitness benefits. Alternative therapies and therapeutic massage are covered with 0% to 50% coinsurance, while several services such as in-home safety assessments, personal emergency response systems, and counseling are not covered.
Hearing Services See details
DEVOTED CHOICE 004 HI (PPO) covers hearing exams with a $50 copay and no coinsurance, which includes one routine exam yearly and unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a $399 to $699 copay for up to two aids per year, though inner ear, outer ear, over the ear, and over-the-counter hearing aids are not covered.
Vision Services See details
DEVOTED CHOICE 004 HI (PPO) partially covers vision services with no deductibles, offering one annual routine eye exam with a copay ranging from no copay to $50 and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay or coinsurance up to a $200 yearly limit for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED CHOICE 004 HI (PPO) covers dental services up to a $1,500 annual maximum with no copay and no coinsurance for preventive care, and no copay with 0% to 50% coinsurance for comprehensive care. Medicare-covered dental services require a $50 copay and no coinsurance, while orthodontics, implants, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE 004 HI (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, chemotherapy, radiation, and other Part B drugs require between no coinsurance and 20% coinsurance, while Part B insulin has a $35 copay and up to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CHOICE 004 HI (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED CHOICE 004 HI (PPO) partially covers medical equipment with no copays, though prior authorization is required. Covered durable medical equipment, prosthetics, and medical and diabetic supplies carry coinsurance ranging from no coinsurance up to 50%, 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) with prior authorization required. Lab services and outpatient X-rays have no copay, diagnostic procedures and tests carry a $0 to $95 copay with no coinsurance, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
DEVOTED CHOICE 004 HI (PPO) covers Home Health Services with no copay and no coinsurance. Prior authorization is required to receive this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services under DEVOTED CHOICE 004 HI (PPO) feature no coinsurance and require prior authorization. Some services are covered, but Cardiac Rehabilitation with a $40 copay, Intensive Cardiac Rehabilitation with a $40 copay, Pulmonary Rehabilitation with a $35 copay, and SET for PAD services with a $25 copay are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by DEVOTED CHOICE 004 HI (PPO) with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and additional days beyond the standard 100-day limit are not covered.
Other Services See details
DEVOTED CHOICE 004 HI (PPO) offers partially covered Other Services, which include 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 and dual eligible SNP highly integrated services are not covered.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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