Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED C-SNP CHOICE PREMIUM 019 TN (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 019 TN (PPO C-SNP) in 2026, please refer to our full plan details page.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) is a PPO C-SNP plan offered by Devoted Health Insurance Company of Tennessee Inc available for the 2026 plan year to people living in Tri-Cities. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that DEVOTED C-SNP CHOICE PREMIUM 019 TN (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 019 TN (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.
Below are a few key facts and commonly-asked questions about DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP).
The cost of a Medicare Advantage Plan is made up of four main parts.
For DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $27.70. 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 that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4200.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $4200.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $6300.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $6300.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
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.
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
The DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) plan features an annual drug deductible of $615. For Tier 1 preferred generic drugs, you will pay an $18 copay for a 1-month supply through standard pharmacies and standard mail order. Tier 2 generic drugs carry a $19 copay for a 1-month supply, while Tier 6 select care drugs are available with no copay. Higher-tier prescription medications under this plan transition to coinsurance costs rather than flat copays. Tier 3 preferred brand drugs require a 21% coinsurance, and Tier 4 non-preferred drugs cost 33% coinsurance for standard pharmacy or standard mail-order services. Tier 5 specialty drugs require a 25% coinsurance for a 1-month supply, helping you plan for your specialized medication needs.
The DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) plan offers comprehensive medical coverage featuring no copay and no coinsurance for primary care visits, select telehealth services, and home health care. For inpatient hospital stays, members pay a $355 daily copay for the first five days and no copay for days six through 90, with no coinsurance required. Emergency room visits carry a $150 copay, while specialist visits require a copay ranging from $30 to $50. This plan also includes valuable supplemental benefits, such as dental coverage up to a $2,000 annual limit with no copay for covered services and a $30 copay for Medicare-covered dental care. Vision benefits feature routine eye exams with no copay to a $30 copay alongside a $300 annual allowance for eyewear, while hearing aid copays range from $399 to $699. Additionally, skilled nursing facility stays have no copay for the first 20 days, and members receive a $50 quarterly allowance for over-the-counter items with no copay.
DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) inpatient hospital benefits are partially covered, featuring no coinsurance and a $355 copay per day for days 1 through 5, with no copay for days 6 through 90. Prior authorization is required, and non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient services are covered by DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) with no coinsurance required across all services. Outpatient hospital services carry a copay ranging from $0 to $455 (including $355 per stay for observation services), outpatient substance abuse sessions have a $30 copay, and both ambulatory surgical center and outpatient blood services are offered with no copay.
DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) covers partial hospitalization services with an $85.00 copay and no coinsurance, though prior authorization is required.
DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) covers ambulance services with prior authorization, featuring ground ambulance services with no copay to a $315 copay and air ambulance services with a 20% coinsurance. Transportation services to health-related locations are not covered under this plan.
DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) covers emergency services with a $150 copay and no coinsurance, which is waived if admitted within 24 hours, and urgent care with no copay to a $45 copay and no coinsurance. Worldwide emergency services are covered up to a $25,000 limit, with a $150 copay and no coinsurance for emergency and urgent care, and a $315 copay with 20% coinsurance for emergency transportation.
DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) provides primary care physician services and select telehealth benefits with no copay and no coinsurance. Specialist visits, mental health, therapy, and podiatry services are covered with copays ranging from $30 to $50 and no coinsurance, though routine and other chiropractic services are not covered.
Preventive services are partially covered by DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) with no copay and no coinsurance for covered services like annual physicals, fitness benefits, and kidney disease education. Non-covered services include in-home safety assessments, PERS, post-discharge medication reconciliation, readmission prevention, chemotherapy wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, extra smoking cessation sessions, enhanced disease management, telemonitoring, remote access technologies, and counseling.
DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) covers hearing exams with a $30 copay and no coinsurance, including one routine exam per year and unlimited fitting evaluations. Prescription hearing aids are partially covered with a copay ranging from $399 to $699 and no coinsurance for up to two aids per year, while inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) offers partially covered vision services with no deductibles, featuring one annual routine eye exam with a $0 to $30 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay or coinsurance up to a $300 annual maximum for contacts, lenses, frames, and upgrades.
DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) offers partially covered dental services up to a $2,000 annual maximum, featuring a $30 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other covered services. Sub-services that are not covered under this plan include other diagnostic services, other preventive services, maxillofacial prosthetics, implant services, and orthodontics.
DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) covers home infusion bundled services with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services are covered under the DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) plan with no copay and a 20% coinsurance. Prior authorization is required to receive these services.
DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) partially covers medical equipment with no copayments, though coinsurance ranges from 20% to 50% for durable medical equipment (DME), up to 20% for prosthetics and medical supplies, and up to 50% for diabetic supplies. Prior authorization is required for these services, and diabetic therapeutic shoes or inserts are not covered.
DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) covers diagnostic services with no coinsurance, offering lab services with no copay and diagnostic tests with a $0 to $95 copay. Covered radiological services require prior authorization and include X-rays with no copay but subject to coinsurance, diagnostic radiology with copays starting at $0 and no coinsurance, and therapeutic radiology with a 20% coinsurance and an applicable copay.
Home health services are covered by the DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac rehabilitation services under the DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) plan require prior authorization and feature no copay and no coinsurance. While some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) 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 and a $218 daily copay for days 21 through 100, though additional days beyond the Medicare limit are not covered.
DEVOTED C-SNP CHOICE PREMIUM 019 TN (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.
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
SMID: MULTIPLAN_HCIHNMEDADVRX27_M
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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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