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DEVOTED DUAL CHOICE 004 MS (PPO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED DUAL CHOICE 004 MS (PPO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) in 2026, please refer to our full plan details page.
DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) is a PPO D-SNP plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Mississippi. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
DEVOTED DUAL CHOICE 004 MS (PPO D-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 DUAL CHOICE 004 MS (PPO D-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 DUAL CHOICE 004 MS (PPO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $23.80. 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 $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 $8950.00 (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 $8950.00 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 Dual Choice 004 MS (PPO D-SNP) has an annual prescription drug deductible of $615. For standard pharmacies and standard mail order, you will pay a 25% coinsurance for Tier 1 through Tier 4 drugs, as well as for a 1-month supply of Tier 5 specialty drugs. In contrast, Tier 6 select care drugs have no copay at standard pharmacies and standard mail order. If you use preferred pharmacies or preferred mail order, you will enjoy no copay or coinsurance for your prescriptions across all tiers. This plan offers an affordable way to manage your medication costs when utilizing preferred network providers.
Additional Benefits
The DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) plan offers comprehensive coverage for core medical services, featuring no copay and no coinsurance for primary care doctor visits, preventive care, and home health services. For inpatient hospital stays, members pay a $275 daily copay for the first 8 or 9 days with no copay for subsequent days, while outpatient hospital services range from no copay up to a $375 copay. Emergency room visits require a $130 copay, which is waived upon admission, and urgently needed care ranges from no copay to a $45 copay. This plan also provides valuable dental, vision, and hearing benefits, including preventive and comprehensive dental care up to $2,000 per year with no copay or coinsurance. Vision benefits include a $375 annual limit for eyewear with no copay, and routine hearing exams are available for a $35 copay. Additionally, members can access a $50 quarterly allowance for over-the-counter items with no copay, and skilled nursing facility stays are covered with no copay for the first 20 days.
Inpatient Hospital See details
DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) partially covers inpatient hospital services with no coinsurance, requiring a $275 daily copay for days 1 through 9 for acute stays and days 1 through 8 for psychiatric stays, with no copay for subsequent days. Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) covers outpatient services with no coinsurance, featuring a copay of $0 to $375 for outpatient hospital services, a $275 copay per stay for observation services, and a $35 copay for 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 of these outpatient benefits.
Partial Hospitalization See details
Partial hospitalization services are covered by DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) with a $70.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) covers ambulance services with prior authorization, requiring a copay ranging from no copay to $315 plus coinsurance for ground transport, and a 20% coinsurance plus a copay for air transport. Transportation services are not covered.
Emergency Services See details
DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) 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 require no copay to a $45 copay with no coinsurance, while worldwide emergency services are covered up to a $25,000 limit with copays up to $315 and 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) provides primary care physician services with no copay and no coinsurance, while other services like specialists, mental health, and physical therapy require copays ranging from $35 to $50 with no coinsurance. Chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are covered by DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes training. Additional preventive benefits are partially covered with no copay and no coinsurance, but do not cover services such as in-home safety assessments, personal emergency response systems, medical nutrition therapy, therapeutic massages, adult day health, in-home support, caregiver support, telemonitoring, and counseling.
Hearing Services See details
DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) covers hearing services, including one routine hearing exam per year for a $35 copay and no coinsurance, alongside unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $399.00 to $699.00 for up to two devices per year, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) partially covers vision services, as other eye exam services are not covered, but routine eye exams are covered with a $0 to $35 copay and no coinsurance. Eyewear is covered with no copay, no coinsurance, and no deductible up to a combined maximum plan benefit of $375 per year for contacts, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) up to a $2,000 annual limit, offering preventive and comprehensive care with no copay and no coinsurance. Medicare-covered dental services require a $35 copay and no coinsurance, while other diagnostic services, other preventive services, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) with no copay, though prior authorization is required. While the bundled service itself has no copay, associated Medicare Part B drugs, including chemotherapy and insulin, are subject to 0% to 20% coinsurance, with insulin also requiring a $35 copay.
Dialysis Services See details
DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required before receiving these services.
Medical Equipment See details
DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) covers medical equipment with no copays, though prior authorization is required for these services. Durable medical equipment carries a 20% to 30% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance up to 20% or 30% coinsurance, with the exception of diabetic therapeutic shoes and inserts which are not covered.
Diagnostic and Radiological Services See details
DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) covers diagnostic and radiological services with prior authorization required. Members pay no copay for lab services and outpatient X-rays, a $0 to $95 copay with no coinsurance for diagnostic procedures and tests, and a minimum 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Home Health Services are covered by DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) does not cover Cardiac Rehabilitation Services in practice, as intensive cardiac, pulmonary, and supervised exercise therapy (SET) services are all not covered. Although the plan technically lists no coinsurance for this category, none of these key sub-services are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) with no coinsurance, featuring no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, a 3-day prior hospital stay is not needed, and additional days beyond the Medicare-covered 100 days are not covered.
Other Services See details
Other services are partially covered by DEVOTED DUAL CHOICE 004 MS (PPO D-SNP), offering additional preventive services and up to $50 every three months for over-the-counter (OTC) items with no copay and no coinsurance. Acupuncture, meal benefits, and highly integrated services for dual-eligible SNPs are not covered under this benefit.
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