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DEVOTED CHOICE PREMIUM 004 IN (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE PREMIUM 004 IN (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED CHOICE PREMIUM 004 IN (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE PREMIUM 004 IN (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Northeast Indiana. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE PREMIUM 004 IN (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 PREMIUM 004 IN (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 PREMIUM 004 IN (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $11.40. 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 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 $10100.00 (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 $10100.00 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 PREMIUM 004 IN (PPO) plan features an annual prescription drug deductible of $615. Under this plan, Tier 1 preferred generic drugs are available with no copay for one, two, or three-month supplies through standard pharmacies and standard mail order. Tier 2 generic drugs are also highly affordable, with copays starting at $3.00 for a one-month supply and standard mail order options costing up to $7.50 for a three-month supply. Higher-tier prescription drugs are covered under coinsurance percentages rather than flat copays. Tier 3 preferred brand drugs require a 22% coinsurance for standard pharmacy and mail order fills. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance, with specialty medications limited to a one-month supply.
Additional Benefits
The DEVOTED CHOICE PREMIUM 004 IN (PPO) plan offers comprehensive medical coverage with no copay for primary care visits and a $35 copay for specialist visits. Inpatient hospital stays require a $295 copay for days 1 through 7, followed by no copay for days 8 through 90, while outpatient services range from no copay to a $395 copay. Additionally, emergency services are covered with a $130 copay, and home health services are available with no copay or coinsurance. This plan also includes key supplemental benefits, featuring a $3,000 yearly limit for dental services with no copay for preventive care and up to 50% coinsurance. Vision benefits include routine exams alongside a $400 annual allowance for eyewear with no copay, while prescription hearing aids require a copay between $199 and $499. Members also benefit from a $125 quarterly allowance for over-the-counter items and skilled nursing facility care with no copay for the first 20 days.
Inpatient Hospital See details
DEVOTED CHOICE PREMIUM 004 IN (PPO) covers inpatient acute and psychiatric hospital services with no coinsurance, requiring a $295 copay for days 1 through 7 and no copay for days 8 through 90. Prior authorization is required, and some services like upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services covered by DEVOTED CHOICE PREMIUM 004 IN (PPO) feature no coinsurance, with copays ranging from no copay for ambulatory surgical center and blood services to $35 for substance abuse sessions and up to $395 for outpatient hospital services. Prior authorization is required for most of these covered services, which also include observation services with a $295 copay per stay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by DEVOTED CHOICE PREMIUM 004 IN (PPO) with a $60.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
DEVOTED CHOICE PREMIUM 004 IN (PPO) covers ambulance services with prior authorization, offering ground ambulance services with a copay ranging from no copay to $315 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Transportation services are not covered under this plan.
Emergency Services See details
DEVOTED CHOICE PREMIUM 004 IN (PPO) covers emergency services with a $130 copay and no coinsurance (waived if admitted within 24 hours), alongside urgently needed services with a $0 to $45 copay and no coinsurance. Worldwide emergency and urgent care are covered up to a $25,000 limit with a $130 copay and no coinsurance, while worldwide emergency transportation requires a $315 copay and 20% coinsurance.
Primary Care See details
DEVOTED CHOICE PREMIUM 004 IN (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $35 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance, excluding routine chiropractic care, whereas podiatry services are not covered. Physical, occupational, and speech therapy services are covered with a $35 to $50 copay and no coinsurance.
Preventive Services See details
Preventive services are partially covered by the DEVOTED CHOICE PREMIUM 004 IN (PPO) plan with no copay and no coinsurance for covered care, including annual physicals, fitness benefits, and kidney disease education. Uncovered sub-services include in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE PREMIUM 004 IN (PPO), featuring routine hearing exams for a $35 copay and no coinsurance, and prescription hearing aids for a $199 to $499 copay and no coinsurance. OTC hearing aids, alongside inner ear, outer ear, and over-the-ear prescription hearing aids, are not covered.
Vision Services See details
DEVOTED CHOICE PREMIUM 004 IN (PPO) partially covers vision services, providing one routine eye exam per year with a $0 to $35 copay and no coinsurance, while other eye exam services are not covered. Covered eyewear, including contacts, lenses, frames, and upgrades, has no copay or coinsurance and features a $400 combined annual maximum for both in-network and out-of-network services.
Dental Services See details
Dental Services are partially covered by DEVOTED CHOICE PREMIUM 004 IN (PPO) with a $3,000 yearly limit, excluding maxillofacial prosthetics, implant services, and orthodontics. Medicare-covered dental requires a $35 copay and no coinsurance, while other covered preventive and comprehensive services have no copay and range from no coinsurance to 50% coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered under DEVOTED CHOICE PREMIUM 004 IN (PPO) with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and insulin, feature no coinsurance to 20% coinsurance, with insulin also requiring a $35 copay.
Dialysis Services See details
DEVOTED CHOICE PREMIUM 004 IN (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED CHOICE PREMIUM 004 IN (PPO) with no copay, requiring a 20% coinsurance for durable medical equipment and no coinsurance to 20% coinsurance for prosthetics, medical supplies, and diabetic supplies. Diabetic therapeutic shoes and inserts are not covered under this plan, and prior authorization is required for most covered equipment.
Diagnostic and Radiological Services See details
DEVOTED CHOICE PREMIUM 004 IN (PPO) covers diagnostic services with prior authorization and no coinsurance, offering lab services at no copay and diagnostic procedures with a $0 to $95 copay. Radiological services are also covered with prior authorization, featuring outpatient X-rays with no copay, diagnostic radiological services starting at no copay, and therapeutic radiological services with a 20% coinsurance.
Home Health Services See details
DEVOTED CHOICE PREMIUM 004 IN (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 not covered under the DEVOTED CHOICE PREMIUM 004 IN (PPO) plan, as all individual sub-services—including cardiac, intensive cardiac, pulmonary, and supervised exercise therapy—are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE PREMIUM 004 IN (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, while additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by DEVOTED CHOICE PREMIUM 004 IN (PPO), offering over-the-counter items with a $125 quarterly limit and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and other extra services are not covered.
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