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DEVOTED CHOICE MA ONLY 004 CO (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE MA ONLY 004 CO (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED CHOICE MA ONLY 004 CO (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE MA ONLY 004 CO (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Colorado. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that DEVOTED CHOICE MA ONLY 004 CO (PPO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about DEVOTED CHOICE MA ONLY 004 CO (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 MA ONLY 004 CO (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. Additionally, this plan comes with a Part B Premium reduction of $165.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
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
Prescription drugs are not covered by DEVOTED CHOICE MA ONLY 004 CO (PPO).
Additional Benefits
The DEVOTED CHOICE MA ONLY 004 CO (PPO) plan offers robust medical coverage with no copay for primary care visits and routine preventive services. For specialized medical care, members will pay copays ranging from $35 to $45 for specialist visits and a $115 copay for emergency services. Inpatient hospital stays require a $425 daily copay for the first four days, after which there is no copay for days 5 through 90. Additional benefits include partially covered dental services up to a $1,000 annual limit with no copay for preventive care and variable coinsurance for restorative services. Vision care features no copay for eyewear up to a $400 annual limit, while hearing benefits include a $45 copay for routine annual exams and copays between $599 and $899 for prescription hearing aids. Most covered services under this plan feature no coinsurance, helping to keep out-of-pocket costs predictable for members.
Inpatient Hospital See details
Inpatient hospital services are covered by DEVOTED CHOICE MA ONLY 004 CO (PPO) with no coinsurance, requiring a $425 daily copay for days 1 through 4 and no copay for days 5 through 90. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, though unlimited additional acute stay days are included.
Outpatient Services See details
DEVOTED CHOICE MA ONLY 004 CO (PPO) covers outpatient services with no coinsurance, featuring a $0 to $525 copay for outpatient hospital services, a $425 copay per stay for observation services, and a $45 copay for outpatient substance abuse sessions. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, and prior authorization is required for most outpatient services.
Partial Hospitalization See details
DEVOTED CHOICE MA ONLY 004 CO (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
DEVOTED CHOICE MA ONLY 004 CO (PPO) partially covers ambulance and transportation services, though transportation services to plan-approved or other health-related locations are not covered. Covered ground ambulance services require a $0 to $350 copay and no coinsurance, while air ambulance services carry a 20% coinsurance and no copay, with prior authorization required for all ambulance transfers.
Emergency Services See details
DEVOTED CHOICE MA ONLY 004 CO (PPO) covers emergency services with a $115 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 $40 copay with no coinsurance, and worldwide emergency services are covered up to $25,000 with a $115 copay (no coinsurance) for emergency or urgent care and a $350 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE MA ONLY 004 CO (PPO) covers primary care visits with no copay and no coinsurance, while chiropractic services are partially covered with no copay and no coinsurance, excluding routine and other chiropractic care. Specialist, occupational therapy, and mental health services require copays ranging from $35 to $45 with no coinsurance, physical therapy requires a $45 to $50 copay with no coinsurance, and podiatry is not covered.
Preventive Services See details
Preventive Services are covered by DEVOTED CHOICE MA ONLY 004 CO (PPO) with no copay and no coinsurance for annual physicals, kidney education, and routine screenings. Additional preventive benefits are partially covered, offering fitness and nutrition with no copay, and alternative therapies or therapeutic massage for 0% to 50% coinsurance. Sub-services including in-home safety assessments, personal emergency response systems, medical nutrition therapy, medication reconciliation, readmission prevention, chemotherapy wigs, adult day health, palliative care, in-home support, caregiver support, tobacco cessation, disease management, telemonitoring, remote technologies, and counseling are not covered.
Hearing Services See details
DEVOTED CHOICE MA ONLY 004 CO (PPO) covers hearing services, offering one routine annual hearing exam for a $45 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $599 to $899 for up to two aids per year, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE MA ONLY 004 CO (PPO) since other eye exam services are not covered. Covered routine eye exams require a $0 to $45 copay and no coinsurance, while eyewear is covered with no copay, no coinsurance, and no deductible up to a $400 annual limit.
Dental Services See details
DEVOTED CHOICE MA ONLY 004 CO (PPO) offers partially covered dental services up to a $1,000 annual limit, featuring no copay and no coinsurance for preventive care, and no copay with 0% to 50% coinsurance for restorative, endodontic, and prosthodontic services. Medicare-covered dental services require a $45 copay and no coinsurance, while orthodontics, implants, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED CHOICE MA ONLY 004 CO (PPO) with no copay and no coinsurance, though prior authorization is required. Covered Medicare Part B drugs under this benefit, such as chemotherapy and insulin, incur a 0% to 20% coinsurance, with insulin also requiring a $35 copay.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CHOICE MA ONLY 004 CO (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED CHOICE MA ONLY 004 CO (PPO) covers medical equipment with no copays, requiring an 18% coinsurance for durable medical equipment and ranging from no coinsurance to 20% coinsurance for prosthetics and medical supplies. Diabetic equipment is partially covered with no copay and ranges from no coinsurance to 18% coinsurance for diabetic supplies, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CHOICE MA ONLY 004 CO (PPO) with prior authorization required. Diagnostic tests range from a $0 to $95 copay with no coinsurance, lab services and X-rays have no copay, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
DEVOTED CHOICE MA ONLY 004 CO (PPO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by DEVOTED CHOICE MA ONLY 004 CO (PPO) with no coinsurance and no copay, although prior authorization is required. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered in practice.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE MA ONLY 004 CO (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the Medicare-covered 100 days are not covered.
Other Services See details
DEVOTED CHOICE MA ONLY 004 CO (PPO) partially covers other services, offering unlimited acupuncture with no copay and 50% coinsurance, as well as additional preventive services with no copay and no coinsurance. Over-the-counter (OTC) items and meal benefits are not covered.
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