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DEVOTED DUAL CHOICE 004 NE (PPO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED DUAL CHOICE 004 NE (PPO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) in 2026, please refer to our full plan details page.
DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) is a PPO D-SNP plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Nebraska. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
DEVOTED DUAL CHOICE 004 NE (PPO D-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 DUAL CHOICE 004 NE (PPO D-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 DUAL CHOICE 004 NE (PPO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $14.40. 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 $6400.00 (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 $6400.00 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 DUAL CHOICE 004 NE (PPO D-SNP) Medicare plan features an annual drug deductible of $615. For Tier 1 preferred generics, Tier 2 generics, Tier 3 preferred brands, and Tier 4 non-preferred drugs, you will pay a 25% coinsurance for 1-month, 2-month, or 3-month supplies at standard pharmacies and through standard mail order. Tier 5 specialty drugs also carry a 25% coinsurance for a 1-month supply at standard pharmacies and standard mail order. For Tier 6 select care drugs, the plan offers no copay for 1-month, 2-month, and 3-month supplies at standard pharmacies and standard mail order. This summary of the DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) prescription drug benefits helps you understand your out-of-pocket costs when choosing a Medicare plan.
Additional Benefits
The DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) offers robust coverage with no copay or coinsurance for primary care visits and preventive services. For hospital care, inpatient stays feature a $300 daily copay for the first six days and no copay thereafter, while outpatient services range from no copay up to a $400 copay. Emergency room visits require a $130 copay, which is waived if you are admitted to the hospital within 24 hours. Specialist visits require a copay of $35 to $50, and dental benefits provide up to $2,000 in preventive and comprehensive care with no copay. Vision care includes a $400 annual eyewear allowance with no copay, and hearing aid coverage is available with copays ranging from $399 to $699. Additionally, members receive a $50 allowance every three months for over-the-counter items with no copay.
Inpatient Hospital See details
DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $300 daily copay for days 1 to 6 and no copay for days 7 to 90. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) covers outpatient services with no coinsurance, featuring copays ranging from no copay to $400 for outpatient hospital services and a $300 copay per stay for observation services. Ambulatory surgical center and blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions require a $35 copay and no coinsurance.
Partial Hospitalization See details
DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) covers partial hospitalization services with a $105.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) covers ground ambulance services with a copay of $0 to $230 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Prior authorization is required for ambulance services, and routine transportation services to plan-approved or health-related locations are not covered.
Emergency Services See details
Emergency services covered by DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) require a $130 copay and no coinsurance, with the copay waived if you are 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 copays ranging from $130 to $230 and up to 20% coinsurance.
Primary Care See details
DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) provides primary care physician services with no copay and no coinsurance, while specialist, therapy, and mental health services require copays ranging from $35 to $50 and no coinsurance. Telehealth benefits are covered with a $0 to $45 copay and no coinsurance, whereas podiatry is not covered, and some chiropractic services are covered but routine and other chiropractic services are not.
Preventive Services See details
DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) offers preventive services with no copay and no coinsurance, including annual physical exams, kidney disease education, and fitness benefits. However, this benefit is partially covered because in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, therapeutic massage, adult day health, palliative care, in-home support, caregiver support, additional tobacco cessation counseling, enhanced disease management, telemonitoring, remote access technologies, and counseling services are not covered.
Hearing Services See details
Hearing services are partially covered by DEVOTED DUAL CHOICE 004 NE (PPO D-SNP), featuring one routine hearing exam per year for a $35 copay and no coinsurance, as well as covered fitting evaluations. Up to two prescription hearing aids are covered annually with a copay ranging from $399 to $699 and no coinsurance, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) offers partially covered vision services, including 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 and glasses, has no copay, no coinsurance, and no deductible, up to a $400 combined annual limit.
Dental Services See details
DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) partially covers dental services, offering Medicare-covered dental with a $35 copay and no coinsurance, and other covered preventive and comprehensive services with no copay and no coinsurance up to a $2,000 annual maximum. Sub-services that are not covered under this plan include other diagnostic services, other preventive services, maxillofacial prosthetics, implants, and orthodontics.
Home Infusion bundled Services See details
DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs have no copay and require no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) with no copay and a 20% coinsurance. Prior authorization is required to receive this benefit.
Medical Equipment See details
Medical Equipment is covered by DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) with no copays and required prior authorization. Covered services include durable medical equipment with 20% to 30% coinsurance, prosthetics and medical supplies with no coinsurance to 20% coinsurance, and diabetic supplies with no coinsurance to 30% coinsurance. This benefit is partially covered because diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED DUAL CHOICE 004 NE (PPO D-SNP), with prior authorization required. Diagnostic services feature no coinsurance, offering no copay for lab services and a $0 to $95 copay for procedures, while radiological services include no copay for outpatient X-rays and a minimum 20% coinsurance for therapeutic radiation.
Home Health Services See details
Home health services are covered by DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) plan, as standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior three-day hospital stay required. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though prior authorization is required and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED DUAL CHOICE 004 NE (PPO D-SNP) partially covers other services, providing additional preventive services and over-the-counter (OTC) items up to $50 every three months with no copay and no coinsurance. However, acupuncture, meal benefits, and highly integrated services for dual-eligible SNPs are not covered.
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