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DEVOTED C-SNP CHOICE PREMIUM 015 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 015 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 015 IN (PPO C-SNP) in 2026, please refer to our full plan details page.
DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) is a PPO C-SNP plan offered by Devoted Health, Inc. available for enrollment in 2026 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 C-SNP CHOICE PREMIUM 015 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 015 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 015 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 015 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 $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 C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) plan features an annual drug deductible of $615. Under this plan, Tier 6 select care drugs are highly accessible with no copay for standard retail pharmacy and standard mail-order fills. For other common medications, Tier 1 preferred generics cost an $18 copay for a one-month supply, while Tier 2 generics require a $19 copay. For brand-name and specialty medications, cost-sharing is based on a percentage of the drug cost rather than a flat copay. Tier 3 preferred brands require 21% coinsurance, Tier 4 non-preferred drugs carry 33% coinsurance, and Tier 5 specialty drugs have a 25% coinsurance for a one-month supply. These coinsurance rates apply to both standard pharmacy and standard mail-order options.
Additional Benefits
The DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) plan offers comprehensive medical coverage with no copay for primary care visits, preventive services, and home health care. For inpatient hospital stays, members pay a $375 daily copay for the first few days and no copay thereafter, while emergency room visits carry a $130 copay that is waived if admitted. Outpatient services and diagnostic tests feature low to no copays, though specialized services like dialysis and Part B drugs require up to a 20% coinsurance. This plan also includes valuable supplemental benefits, featuring no copay for routine dental services up to a $2,000 yearly limit and no copay for eyewear up to a $300 annual allowance. Routine hearing exams require a $40 copay, while skilled nursing facility stays have no copay for the first 20 days. Additionally, members receive a $50 allowance every three months for over-the-counter items with no copay, though routine transportation and meals are not covered.
Inpatient Hospital See details
DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) covers inpatient acute and psychiatric hospital stays with no coinsurance, featuring a $375 daily copay for the first 7 days of acute stays and the first 6 days of psychiatric stays, followed by no copay. Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center services and outpatient blood services. Outpatient hospital services have a copay ranging from $0 to $475, while outpatient substance abuse sessions cost a $40 copay and observation services require a $375 copay per stay, with prior authorization required.
Partial Hospitalization See details
Partial hospitalization is covered under the DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) plan, requiring a $60.00 copay and no coinsurance. Prior authorization is required to receive this care.
Ambulance and Transportation Services See details
DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) covers ground ambulance services with a copay ranging from no copay to $315 and air ambulance services with a 20% coinsurance, with prior authorization required for all ambulance services. Transportation services are not covered, as the plan does not cover trips to plan-approved or any health-related locations.
Emergency Services See details
DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) covers emergency services with a $130 copay (waived if admitted within 24 hours) and urgently needed services with a copay ranging from no copay to $45, both with no coinsurance and no deductible. Worldwide emergency and urgent care are covered up to $25,000 with a $130 copay and no coinsurance, while worldwide emergency transportation costs a $315 copay and 20% coinsurance.
Primary Care See details
DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) offers primary care physician services with no copay and no coinsurance, while specialist visits, mental health, and therapy services feature copays ranging from $40 to $50 and no coinsurance. Some chiropractic services are covered, but routine chiropractic care and other chiropractic services are not covered.
Preventive Services See details
DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) covers preventive services with no copay and no coinsurance, including annual physical exams and kidney disease education. Additional preventive services are partially covered, excluding in-home safety assessments, personal emergency response systems, post-discharge medication reconciliation, re-admission prevention, chemo wigs, therapeutic massage, adult day health, palliative care, in-home support, caregiver support, extra smoking cessation, disease management, telemonitoring, remote access, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP), featuring a $40 copay and no coinsurance for routine hearing exams. Prescription hearing aids have no coinsurance and a copay of $399 to $699 for up to two aids per year, though OTC hearing aids, inner ear, outer ear, and over the ear prescription aids are not covered.
Vision Services See details
DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) vision services are partially covered, offering routine eye exams with a $0 to $40 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and a $300 annual maximum allowance for contacts, frames, lenses, and upgrades.
Dental Services See details
Dental Services are partially covered by DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP), featuring a $40 copay and no coinsurance for Medicare dental, and no copay and no coinsurance for other covered services up to a $2,000 yearly limit. While routine cleanings, exams, and restorative care are covered, other diagnostic services, other preventive services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) covers home infusion bundled services with no copay, subject to prior authorization. Under this plan, Medicare Part B chemotherapy, radiation, and other drugs have no copay and a coinsurance ranging from no coinsurance to 20%, while Part B insulin is covered with a $35 copay and up to 20% coinsurance.
Dialysis Services See details
DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) 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 C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) with no copays, though coinsurance ranges from no coinsurance up to 40% and prior authorization is required. While durable medical equipment, prosthetics, and diabetic supplies are covered, diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) covers diagnostic and radiological services, requiring prior authorization for both. Diagnostic procedures and tests carry a copay of $0 to $95 with no coinsurance, while lab services have no copay and no coinsurance. Outpatient x-rays and diagnostic radiology services feature no copay, while therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) offers Cardiac Rehabilitation Services with no coinsurance, but only some services are covered. Specifically, Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) services are not covered, with copays ranging from $25 to $40.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) 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, no prior three-day hospital stay is needed, and additional days beyond the standard 100 days are not covered.
Other Services See details
DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) partially covers other services, offering no copay and no coinsurance for over-the-counter items up to $50 every three months, diabetic shoes, and additional preventive services. Acupuncture and meal benefits are not covered under this plan.
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* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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