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DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED C-SNP CHOICE PREMIUM 014 IN (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 PREMIUM 014 IN (PPO C-SNP) in 2026, please refer to our full plan details page.
DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) is a PPO C-SNP plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Central Indiana. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED C-SNP CHOICE PREMIUM 014 IN (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 PREMIUM 014 IN (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 PREMIUM 014 IN (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 PREMIUM 014 IN (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 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 $7100.00 (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 $7100.00 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 C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) Medicare prescription drug plan features an annual drug deductible of $615. Under this plan, Tier 6 Select Care Drugs are available with no copay for standard pharmacy and mail-order prescriptions. For Tier 1 Preferred Generics, you will pay an $18 copay for a 1-month supply, while Tier 2 Generics require a $19 copay for a 1-month supply through standard retail or mail-order services. Brand-name and specialty medications under this plan are subject to coinsurance rather than flat copays. Tier 3 Preferred Brands require a 21% coinsurance, and Tier 4 Non-Preferred Drugs have a 33% coinsurance. Additionally, Tier 5 Specialty Tier drugs require a 25% coinsurance for a 1-month supply at standard pharmacies and through standard mail order.
Additional Benefits
The DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) plan offers comprehensive medical coverage with no copay for primary care doctor visits and home health services. For inpatient hospital stays, members pay a daily copay of $470 for the first five days of acute stays and no copay for subsequent days, while outpatient hospital services range from no copay to a $570 copay. Emergency care is available with a $130 copay, which is waived upon hospital admission, and urgent care visits feature no copay to a $45 copay. This plan also includes valuable routine benefits, such as dental coverage up to a $2,000 annual limit with no copay for routine cleanings and fillings. Vision care features no deductibles and no copay for eyewear up to a $300 yearly maximum, while routine hearing exams require a $35 copay. Additionally, members can access a $50 quarterly over-the-counter allowance and enjoy no copay for skilled nursing facility stays during the first 20 days.
Inpatient Hospital See details
DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) covers inpatient hospital services with no coinsurance, requiring a $470 daily copay for days 1 to 5 of acute stays and days 1 to 4 of psychiatric stays, followed by no copay for subsequent covered days. Non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) covers outpatient services with no coinsurance for all services, featuring no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $570 ($470 per stay for observation services), and outpatient substance abuse sessions have a $35 copay.
Partial Hospitalization See details
DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) covers partial hospitalization services with a $60.00 copay and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) covers ground ambulance services with no coinsurance and a copay ranging from no copay up to $315, while air ambulance services require a 20% coinsurance and no copay. Prior authorization is required for all ambulance services, and transportation services to health-related locations are not covered.
Emergency Services See details
Emergency services under DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) are covered with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no copay to a $45 copay with no coinsurance, while worldwide emergency services are covered up to a $25,000 maximum with copays up to $315 and up to 20% coinsurance for transportation.
Primary Care See details
DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) offers primary care physician visits with no copay and no coinsurance, while specialist, mental health, and podiatry services require a $35 copay and no coinsurance. Physical and occupational therapies range from a $35 to $50 copay with no coinsurance, telehealth services range from no copay to a $45 copay, and chiropractic care is only partially covered because routine services are excluded.
Preventive Services See details
Preventive services under the DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) plan are partially covered with no copay and no coinsurance for covered benefits like annual physicals and kidney disease education. Non-covered sub-services include in-home safety assessments, PERS, post-discharge medication reconciliation, re-admission prevention, chemotherapy 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 C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP), offering routine hearing exams for a $35 copay and no coinsurance, and up to two prescription hearing aids per year for a $399 to $699 copay and no coinsurance. However, OTC hearing aids as well as inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) offers partially covered vision services with no deductibles, including one annual routine eye exam with a copay ranging from no copay to $35 and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance, providing a $300 yearly maximum for contacts, lenses, frames, and upgrades.
Dental Services See details
DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) dental services are partially covered, featuring up to a $2,000 annual maximum benefit for both in-network and out-of-network care. Medicare-covered dental services require a $35 copay and no coinsurance, while other covered services like exams, cleanings, and fillings have no copay and no coinsurance, though implants, orthodontics, maxillofacial prosthetics, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) with no copay, though prior authorization is required. Under this benefit, Part B chemotherapy and other drugs have no copay and no coinsurance to 20% coinsurance, while insulin is covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required for these covered services.
Medical Equipment See details
DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment has a 20% to 50% coinsurance, prosthetics and medical supplies range from no coinsurance to 20% coinsurance, and diabetic supplies range from no coinsurance to 50% coinsurance, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) covers diagnostic and radiological services with prior authorization, featuring no coinsurance for diagnostic services, no copay for lab services, and diagnostic test copays ranging from $0 to $95. Outpatient X-rays and diagnostic radiology services start at a $0 copay, while therapeutic radiological services carry a minimum 20% coinsurance.
Home Health Services See details
DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) 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 C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) with no coinsurance and required prior authorization, but only some services are covered in practice. Standard cardiac rehabilitation, intensive cardiac rehabilitation, and pulmonary rehabilitation services are not covered and require a $35 copay, while SET for PAD services are also not covered and require a $25 copay.
Skilled Nursing Facility (SNF) See details
DEVOTED C-SNP CHOICE PREMIUM 014 IN (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, though a prior three-day inpatient hospital stay is not, and additional days beyond the standard 100-day benefit period are not covered.
Other Services See details
DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) partially covers other services, offering over-the-counter items, non-Medicare diabetic shoes, and additional preventive services with no copay and no coinsurance. Acupuncture and meal benefits are not covered under this benefit, and the over-the-counter benefit has a maximum limit of $50 every three months.
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