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DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) in 2026, please refer to our full plan details page.
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) is a PPO C-SNP plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Kentucky. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP).
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 C-SNP CHOICE PLUS 004 KY (PPO C-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $38.40. 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 has a $990.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $615.00 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 $13900.00 (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 $13900.00 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:
Sign up for DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP)
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Drug Coverage
The DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) Medicare plan features an annual prescription drug deductible of $615. For Tier 1 preferred generic drugs, you will pay an $18 copay for a 1-month supply at standard pharmacies and mail-order services, while Tier 2 generic drugs carry a $19 copay. Tier 6 select care drugs are highly accessible with no copay required for 1-month, 2-month, or 3-month supplies through standard retail or mail order. For brand-name and specialty medications, Tier 3 preferred brand drugs require a 25% coinsurance, and Tier 4 non-preferred drugs require a 31% coinsurance. Tier 5 specialty drugs also carry a 25% coinsurance for a 1-month supply through standard pharmacies and mail order. This clear pricing structure allows you to accurately plan your healthcare budget based on your specific prescription needs.
Additional Benefits
The DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) plan offers robust coverage with no copay and no coinsurance for primary care, preventive services, and home health care. For inpatient hospital stays, members pay no coinsurance but are responsible for a $2,230 copay for acute care or a $2,080 copay for psychiatric care. Outpatient services and specialist visits also feature no copay, though they require coinsurance of up to 50% and 30% respectively. Supplemental benefits include dental services up to a $4,000 annual limit and eyewear up to $300 annually, both featuring no copay and no coinsurance for covered services. Hearing exams are covered with no copay and 50% coinsurance, while prescription hearing aids require a copay between $399 and $699. Additionally, skilled nursing facility stays require no copay for the first 20 days, followed by a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) inpatient hospital benefits are partially covered, requiring no coinsurance alongside a $2,230 copay per stay for acute care and a $2,080 copay per stay for psychiatric care. Under this plan, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) covers outpatient services with no copay, though coinsurance and prior authorization are required for most care. Patients will pay between no coinsurance and 50% coinsurance for outpatient hospital and ambulatory surgical center services, and a 30% coinsurance for outpatient substance abuse and blood services.
Partial Hospitalization See details
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) covers partial hospitalization services with no copay and a 20% coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) covers ambulance services with no copay, requiring prior authorization and a coinsurance of no coinsurance to 50% for ground ambulance and 50% coinsurance for air ambulance. Although transportation is listed as covered, specific transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) covers emergency services with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services are covered with no copay and a 0% to 20% coinsurance (up to $40 per visit), while worldwide emergency, urgent, and transportation services are covered up to a $25,000 maximum with no copay and no coinsurance.
Primary Care See details
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) offers primary care physician services with no copay and no coinsurance. Most other services, including specialist visits, therapy, mental health, and podiatry, feature no copay and 30% coinsurance, while some chiropractic services are covered but routine and other chiropractic care are not. Telehealth options are also available with no copay and 0% to 30% coinsurance.
Preventive Services See details
Preventive services are partially covered by DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) with no copay and no coinsurance for covered care, including annual physical exams, kidney disease education, and fitness benefits. However, certain additional services such as in-home support, personal emergency response systems, and therapeutic massages are not covered.
Hearing Services See details
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) covers hearing exams with no copay and a 50% coinsurance for routine visits, as well as prescription hearing aids with no coinsurance and a $399 to $699 copay. This benefit is partially covered because over-the-counter (OTC) hearing aids, along with 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 C-SNP CHOICE PLUS 004 KY (PPO C-SNP), offering one annual routine eye exam with no copay and 0% to 50% coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a combined annual maximum of $300 for both in-network and out-of-network contacts, lenses, frames, and upgrades.
Dental Services See details
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) partially covers dental services up to a $4,000 annual maximum limit with no copay and no coinsurance for most preventive and comprehensive services, though Medicare-covered dental services require a 30% coinsurance and no copay. Other diagnostic services, other preventive services, maxillofacial prosthetics, implant services, and orthodontics are not covered under this plan.
Home Infusion bundled Services See details
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) covers home infusion bundled services with no copay, subject to prior authorization. Medicare Part B chemotherapy, radiation, and other drugs are covered with no copay and no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) with no copays and coinsurance ranging from no coinsurance up to 20% for covered items. While durable medical equipment, prosthetic devices, medical supplies, and diabetic supplies are covered, diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) plan with no copays, though prior authorization is required. Diagnostic procedures and tests require no coinsurance, while a 50% coinsurance applies to lab services, diagnostic radiological services, and outpatient X-rays, and a 20% coinsurance applies to therapeutic radiological services.
Home Health Services See details
Home Health Services are covered by DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) with no copay and prior authorization required, meaning some services are covered; however, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered and carry a 30% coinsurance.
Skilled Nursing Facility (SNF) See details
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) 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 3-day hospital stay is not required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) partially covers other services, providing over-the-counter (OTC) items up to $50 every three months, non-Medicare covered diabetic shoes, and additional preventive services with no copay and no coinsurance. Acupuncture and meal benefits are not covered under this plan.
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