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DEVOTED DUAL CHOICE 004 AR (PPO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED DUAL CHOICE 004 AR (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 AR (PPO D-SNP) in 2026, please refer to our full plan details page.
DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) is a PPO D-SNP plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Arkansas. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED DUAL CHOICE 004 AR (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 AR (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 AR (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 AR (PPO D-SNP), 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 $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 $9550.00 (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 $9550.00 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 AR (PPO D-SNP) Medicare plan features an annual prescription drug deductible of $615.00. During the initial coverage phase, members pay a 25% coinsurance for Tier 1 preferred generics, Tier 2 standard generics, Tier 3 preferred brands, and Tier 4 non-preferred drugs at standard pharmacies and standard mail services. Notably, there is no copay for Tier 5 specialty drugs during this phase. If you qualify for the low-income subsidy or Extra Help, your Part D cost-sharing is reduced to $0.00. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and will pay nothing for Medicare Part D covered drugs.
Additional Benefits
The DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) plan offers comprehensive medical coverage featuring no copay for preventive services, laboratory tests, and outpatient X-rays. For inpatient hospital stays, members pay a $340 daily copay for days one through six and no copay for days seven through 90. Doctor visits and specialist consultations are highly affordable, with copays ranging from no copay to $50 and no coinsurance. Additional benefits include a $2,000 yearly dental limit with no copay for most covered services, and a $400 annual eyewear allowance with no copay or deductible. Members can also access routine hearing exams for a $35 copay and receive a $50 quarterly allowance for over-the-counter health items. However, certain services like cardiac rehabilitation, routine chiropractic care, and health-related transportation are not covered by this plan.
Inpatient Hospital See details
DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) covers inpatient acute and psychiatric hospital stays with a $340 daily copay for days 1 through 6, no copay for days 7 through 90, and no coinsurance. 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 AR (PPO D-SNP) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center services and outpatient blood services. Other covered services require copays, including $35 for outpatient substance abuse sessions, $340 per stay for observation services, and $0 to $440 for outpatient hospital services.
Partial Hospitalization See details
DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to access these covered benefits.
Ambulance and Transportation Services See details
DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) ambulance and transportation services are partially covered, as transportation services to plan-approved or any health-related locations are not covered. Covered ground ambulance services require coinsurance and a copay ranging from no copay to $350, while air ambulance services require a 20% coinsurance and a copay, with prior authorization required for all ambulance services.
Emergency Services See details
DEVOTED DUAL CHOICE 004 AR (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 range from no copay to a $45 copay with no coinsurance, and worldwide emergency services are covered up to a $25,000 limit with copays ranging from $130 to $350 and up to 20% coinsurance.
Primary Care See details
Primary care benefits are partially covered under DEVOTED DUAL CHOICE 004 AR (PPO D-SNP), as podiatry services and routine chiropractic care are not covered. Covered services—including PCP visits, specialists, mental health, and physical therapy—require copays ranging from $0 to $50 and no coinsurance.
Preventive Services See details
DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) covers preventive services with no copay and no coinsurance for Medicare-covered zero-dollar preventive services, annual physicals, and kidney education. However, this benefit is only partially covered, as services such as in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, in-home medication reconciliation, readmission prevention, chemotherapy wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional tobacco cessation counseling, enhanced disease management, telemonitoring, remote access technologies, and counseling are not covered.
Hearing Services See details
Hearing services are partially covered by DEVOTED DUAL CHOICE 004 AR (PPO D-SNP), featuring a $35 copay and no coinsurance for an annual routine hearing exam. The plan covers up to two prescription hearing aids per year with a copay ranging from $399 to $699 and no coinsurance, while OTC hearing aids and specific inner ear, outer ear, and over-the-ear prescription models are not covered.
Vision Services See details
DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) covers annual routine eye exams with a copay ranging from $0 to $35 and no coinsurance. The plan also covers eyewear, including contacts and eyeglasses, with a combined maximum benefit of $400 per year and no copay, coinsurance, or deductible.
Dental Services See details
DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) offers partially covered dental services with a $2,000 yearly maximum, though maxillofacial prosthetics, implant services, and orthodontics are not covered. Medicare-covered dental services require a $35 copay and no coinsurance, while other covered dental services have no copay and no coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) with prior authorization required. Medicare Part B insulin drugs require a $35 copay and 0% to 20% coinsurance, while chemotherapy, radiation, and other Part B drugs feature no copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) with 20% coinsurance and no copay. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) covers medical equipment with no copays, requiring a 20% to 30% coinsurance for durable medical equipment and up to 20% coinsurance for prosthetics and medical supplies. Diabetic equipment is partially covered, with diabetic supplies ranging from no coinsurance to 30% coinsurance, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) with prior authorization, featuring no copay for lab services and outpatient X-rays. Members will pay a copay of $0 to $95 for diagnostic tests, a copay of $0 to $300 for diagnostic radiological services, and a 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Home Health Services are covered under the DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) plan, though prior authorization is required before receiving these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) plan. This lack of coverage includes cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD).
Skilled Nursing Facility (SNF) See details
DEVOTED DUAL CHOICE 004 AR (PPO D-SNP) covers Skilled Nursing Facility (SNF) services with prior authorization, requiring no copay for days 1 to 20, a $218 daily copay for days 21 to 100, and no coinsurance. The benefit is partially covered because additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by DEVOTED DUAL CHOICE 004 AR (PPO D-SNP), which provides a $50 quarterly allowance for over-the-counter items and coverage for additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and highly integrated services for dual eligible SNPs are not covered.
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