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DEVOTED CHOICE 005 KS (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE 005 KS (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED CHOICE 005 KS (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE 005 KS (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Kansas River Valley Area. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE 005 KS (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 005 KS (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 005 KS (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 $375.00 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 $5600.00 (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 $5600.00 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 005 KS (PPO) Medicare plan features an annual drug deductible of $375. Under this plan, Tier 1 preferred generic and Tier 2 generic medications have no copay for one-month, two-month, or three-month supplies filled at standard pharmacies or through standard mail order. This provides cost-effective access to essential daily medications. For brand-name and specialty prescriptions, costs are calculated as a percentage of the drug cost. Tier 3 preferred brand drugs require a 19% coinsurance, while Tier 4 non-preferred drugs carry a 25% coinsurance for both standard pharmacy and standard mail-order fills. Tier 5 specialty drugs require a 28% coinsurance for a one-month supply.
Additional Benefits
The DEVOTED CHOICE 005 KS (PPO) plan offers comprehensive medical coverage with no copay for primary care visits and no coinsurance for inpatient hospital stays. Inpatient stays require a $295 daily copay for the first six days, while outpatient services and diagnostic lab tests feature no copay for many standard services. Emergency care is covered with a $150 copay, which is waived if you are admitted to the hospital within 24 hours. This plan also provides valuable extra benefits, including a $3,500 annual dental limit with no copay for preventive care and a $400 yearly allowance for eyewear. Members can access routine hearing exams and home health services with no copay, alongside a $100 quarterly allowance for over-the-counter items. Covered durable medical equipment and dialysis services generally carry a 20% to 25% coinsurance with no copay.
Inpatient Hospital See details
DEVOTED CHOICE 005 KS (PPO) covers inpatient hospital services with no coinsurance, requiring a $295 daily copay for days 1 through 6 and no copay for days 7 through 90. This benefit is partially covered as unlimited additional days are included for acute care, but psychiatric additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED CHOICE 005 KS (PPO) covers outpatient services with no coinsurance, offering ambulatory surgical center and blood services with no copay. Outpatient hospital services require a copay of $0 to $395, observation services cost $295 per stay, and outpatient substance abuse sessions carry a $25 copay, with prior authorization required for these benefits.
Partial Hospitalization See details
Partial hospitalization is covered by DEVOTED CHOICE 005 KS (PPO) with a $130.00 copay and no coinsurance. Prior authorization is required to receive these services.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by DEVOTED CHOICE 005 KS (PPO), as transportation services to plan-approved or any health-related locations are not covered. Covered ground ambulance services require a copay ranging from no copay to $350 with no coinsurance, while air ambulance services carry a 20% coinsurance with no copay.
Emergency Services See details
Emergency services are covered by DEVOTED CHOICE 005 KS (PPO) with a $150 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours. Urgently needed services require no copay to a $45 copay with no coinsurance, while worldwide emergency services are covered up to $25,000 with a $150 copay for emergency/urgent care and a $350 copay plus 20% coinsurance for transportation.
Primary Care See details
DEVOTED CHOICE 005 KS (PPO) offers primary care physician services with no copay and no coinsurance, while specialist, mental health, psychiatric, and opioid treatment services require a $25 copay and no coinsurance. Physical, occupational, and speech therapies have a $25 to $50 copay and no coinsurance, telehealth ranges from no copay to a $45 copay with no coinsurance, some chiropractic services are covered but routine and other chiropractic services are not covered, and podiatry is not covered.
Preventive Services See details
Preventive services are partially covered by DEVOTED CHOICE 005 KS (PPO) with no copay and no coinsurance for covered benefits like annual physicals, fitness programs, and alternative therapies. However, certain options such as in-home support, therapeutic massages, personal emergency response systems, and counseling are not covered.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE 005 KS (PPO), featuring a $25 copay and no coinsurance for annual routine exams and unlimited fitting evaluations. Prescription hearing aids are covered with no coinsurance and a $399 to $699 copay for up to two aids per year, but OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
DEVOTED CHOICE 005 KS (PPO) covers routine eye exams once per year with a $0 to $25 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay or coinsurance, offering a combined maximum benefit of $400 per year for contacts, eyeglasses, lenses, frames, and upgrades.
Dental Services See details
DEVOTED CHOICE 005 KS (PPO) offers partially covered dental services with a $3,500 annual limit, featuring no copay and no coinsurance for preventive care, periodontics, and oral surgery. Medicare-covered dental services require a $25 copay and no coinsurance, while restorative, endodontic, and prosthodontic services have no copay and 0% to 50% coinsurance; however, orthodontics, implants, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE 005 KS (PPO) covers Home Infusion bundled Services with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs feature no copay and coinsurance ranging from no coinsurance to 20%, while Part B insulin is covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CHOICE 005 KS (PPO) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
DEVOTED CHOICE 005 KS (PPO) offers partial coverage for medical equipment with no copays, though prior authorization is required and diabetic therapeutic shoes and inserts are not covered. Covered durable medical equipment has a 20% to 25% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance up to 20% or 30% coinsurance.
Diagnostic and Radiological Services See details
DEVOTED CHOICE 005 KS (PPO) covers diagnostic and radiological services with no coinsurance for diagnostic services, no copay for lab and outpatient X-ray services, and diagnostic test copays ranging from $0 to $95. Diagnostic radiological services start at no copay, therapeutic radiological services require a minimum 20% coinsurance, and prior authorization is required.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE 005 KS (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE 005 KS (PPO) provides coverage for some Cardiac Rehabilitation Services with no coinsurance, though prior authorization is required. However, Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) services are not covered and require a $25 copay.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE 005 KS (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior three-day hospital stay required, though prior authorization is necessary. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, with no coverage provided for additional days beyond the standard Medicare limit.
Other Services See details
DEVOTED CHOICE 005 KS (PPO) covers select other services with no copay and no coinsurance, including additional preventive services and up to $100 every three months for over-the-counter (OTC) items. However, acupuncture and meal benefits are not covered under this plan.
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