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DEVOTED C-SNP CHOICE PREMIUM 016 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 016 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 016 IN (PPO C-SNP) in 2026, please refer to our full plan details page.
DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) is a PPO C-SNP plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Northwest/North 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 016 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 016 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 016 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 016 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 $9850.00 (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 $9850.00 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 016 IN (PPO C-SNP) plan features an annual drug deductible of $615. For Tier 6 select care drugs, there is no copay for up to a three-month supply through standard pharmacies or standard mail order. Tier 1 preferred generic drugs require an $18 copay for a one-month supply, while Tier 2 generic drugs carry a $19 copay for a one-month supply. Higher-tier medications under this plan are subject to coinsurance rather than flat copays. Tier 3 preferred brand drugs require 21% coinsurance, and Tier 4 non-preferred drugs carry a 33% coinsurance for standard pharmacy and mail order services. Tier 5 specialty drugs require 25% coinsurance for a one-month supply.
Additional Benefits
The DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) plan offers comprehensive healthcare coverage with no copay for primary care doctor visits and eligible preventive services. For inpatient hospital stays, members pay a $470 copay for the first five days of an acute stay and no copay for subsequent days. Outpatient services are also highly affordable, featuring no copay for ambulatory surgical centers and specialist visit copays ranging from no copay to $50. In addition to medical care, this plan provides valuable dental and vision benefits, including dental services with no copay up to a $2,000 annual limit and eyewear coverage up to a $300 annual maximum. Members also benefit from a $50 over-the-counter allowance every three months with no copay, as well as routine hearing exams for a $45 copay. Emergency room visits require a $130 copay, which is completely waived if you are admitted to the hospital within 24 hours.
Inpatient Hospital See details
DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) covers inpatient hospital services with no coinsurance, requiring a $470 copay for days 1 through 5 of an acute stay and days 1 through 4 of a psychiatric stay, with no copay for subsequent days. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) covers outpatient services with no coinsurance, featuring a $0 to $570 copay for outpatient hospital services and a $470 copay per stay for observation services. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions carry a $45 copay and no coinsurance.
Partial Hospitalization See details
DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) covers partial hospitalization services with a $60.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) covers ground ambulance services with a copay of $0 to $315 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, both requiring prior authorization. Transportation services to plan-approved or health-related locations are not covered.
Emergency Services See details
DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) covers emergency services with a $130 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours. Urgently needed services range from no copay to a $45 copay with no coinsurance, while worldwide emergency services are covered up to $25,000 with a $130 copay for emergency or urgent care, and a $315 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
Primary care benefits are partially covered by DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP), as routine and other chiropractic services are not covered. Covered services feature no coinsurance, with no copay for primary care physician visits and copays ranging from $0 to $50 for specialists, occupational and physical therapies, mental health, and telehealth services.
Preventive Services See details
Preventive services are covered by DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) with no copay and no coinsurance for eligible services like annual physical exams, kidney disease education, and fitness benefits. This benefit is partially covered because several sub-services are not covered, including in-home safety assessments, personal emergency response systems (PERS), post-discharge medication reconciliation, therapeutic massage, and in-home support services.
Hearing Services See details
DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) offers partially covered hearing services, featuring a $45 copay and no coinsurance for routine exams, and prescription hearing aid copays ranging from $399 to $699 with no coinsurance. Fitting evaluations are covered, but OTC hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP), offering one routine eye exam per year with a $0 to $45 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, providing up to a $300 annual maximum for contacts, lenses, frames, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) with no copay and no coinsurance up to a $2,000 annual maximum, though Medicare-covered dental services require a $45 copay and no coinsurance. Sub-services that are not covered include other diagnostic dental, other preventive dental, maxillofacial prosthetics, implant services, and orthodontics.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) with no copay and no coinsurance, though prior authorization is required. Associated Medicare Part B drugs, including insulin, chemotherapy, and other drugs, are covered with a coinsurance of 0% to 20%, with insulin also requiring a $35 copay.
Dialysis Services See details
DEVOTED C-SNP CHOICE PREMIUM 016 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
DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) offers medical equipment coverage with no copays, though prior authorization is required. Durable medical equipment carries a 20% to 30% coinsurance, prosthetics and medical supplies range from no coinsurance to 20% coinsurance, and diabetic equipment is partially covered with no coinsurance to 35% coinsurance for supplies, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) covers diagnostic and radiological services with prior authorization required. Lab services and outpatient X-rays are covered with no copay, diagnostic procedures carry no coinsurance with a copay ranging from $0 to $95, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) covers cardiac rehabilitation services with no coinsurance, though only some services are covered in practice. Specifically, standard cardiac rehabilitation ($40 copay), intensive cardiac rehabilitation ($40 copay), pulmonary rehabilitation ($35 copay), and SET for PAD services ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) covers Skilled Nursing Facility (SNF) care with no coinsurance, requiring prior authorization but allowing admission without a prior three-day hospital stay. There is no copay for days 1 through 20 and a $218 copay for days 21 through 100, though additional days beyond the standard 100-day limit are not covered.
Other Services See details
DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) partially covers other services, offering no copay and no coinsurance for over-the-counter (OTC) items up to $50 every three months, diabetic shoes, and additional preventive services. Acupuncture, meal benefits, and highly integrated dual eligible SNP services are not covered.
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