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DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) - H5718-004-000
$38.40
Monthly Premium
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) is a PPO C-SNP Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H5718-004-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$38.40
Monthly Premium
Kentucky Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other additional benefits Original Medicare doesn’t cover.
Learn more about Kentucky Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $38.40 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $615.00 |
| Out-of-pocket maximum | $9,250.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Coinsurance for Physician Specialist Office Visit 30% Prior Authorization Required for Doctor Specialty Visit Cost share applies to wound care services, facet injections, cortisol injections, and specialist services. |
| Inpatient hospital care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $2230 Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Coinsurance for Urgent Care 0% to 20% The min cost share applies to urgently needed services received by a PCP. The max cost share applies to urgently needed services received from an urgent care center. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0 Maximum Plan Benefit of $25,000 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $115 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0 Copayment for Worldwide Emergency Transportation (Ground) $0 Maximum Plan Benefit of $25,000 |
| Ambulance transportation | In-Network: Ground Ambulance: Coinsurance for Ground Ambulance Services 0% to 50% Cost share applies per trip. Min cost share for facility to facility transfers. Max cost share for all other ambulance services. Air Ambulance: Coinsurance for Air Ambulance Services 50% Prior Authorization Required for Air Ambulance Cost share applies per trip. |
Health Care Services and Medical Supplies
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) covers a range of additional benefits. Learn more about DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Coinsurance for Medicare-covered Diabetic Supplies 20% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 |
| Durable medical equipment (DME) | Out-of-Network: Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 50% |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare-covered Diagnostic Procedures/Tests 0% to 50% Coinsurance for Medicare-covered Lab Services 50% Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Cost share varies based on site of service:PCPs office: No cost share for EKGs/EEGs/ECGs, no cost share all other. Specialist office: No cost share for EKGs/EEGs/ECGs, 50% coinsurance all other. Freestanding facility: 50% coinsurance for EKGs/EEGs/ECGs, 50% coinsurance all other. Outpatient hospital: 50% coinsurance for EKGs/EEGs/ECGs, 50% coinsurance all other. No cost share for home sleep studies. No cost share for remote patient monitoring services. Outpatient Diag/Therapeutic Rad Services: Coinsurance for Medicare-covered Diagnostic Radiological Services 50% Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Coinsurance for Medicare-covered X-Ray Services 50% |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 40% |
| Mental health outpatient care | Out-of-Network: Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Outpatient services/surgery | Out-of-Network: Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 0% to 50% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 0% to 50% The min cost share applies to diagnostic colonoscopies, the max cost share applies to all other outpatient hospital services. |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Over-the-counter items | Out-of-Network: Over-The-Counter (OTC) Items Services: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0 Maximum Plan Benefit of $50 |
| Podiatry services | In-Network: Podiatry Services: Coinsurance for Medicare-Covered Podiatry Services 30% Copayment for Routine Foot Care $0
|
| Skilled Nursing Facility (SNF) care | Out-of-Network: Skilled Nursing Facility Services: Coinsurance for Skilled Nursing Facility per Stay 40% |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Medicare Covered Preventive Dental: Coinsurance for Office Visit 30% Prior Authorization Required for Medicare Covered Preventive Dental Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0
Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0
|
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Coinsurance for Medicare Covered Benefits 0% to 50% Copayment for Routine Eye Exams $0
The min cost share applies to diabetic retinopathy exams. The max cost share applies to other Medicare-covered eye exams. Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0 Copayment for Eyeglasses (lenses and frames) $0 Copayment for Eyeglass Lenses $0 Copayment for Eyeglass Frames $0 Copayment for Upgrades $0 Maximum Plan Benefit of $300 every year |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Coinsurance for Medicare Covered Benefits 50% Copayment for Routine Hearing Exams $0
Prior Authorization Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $399 to $699
|
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) offers prescription drug coverage, with an annual drug deductible of $615.00 (excludes Tier 6)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $615.00 (excludes Tier 6) |
| Tier 6 |
|
| Annual drug deductible | $615.00 (excludes Tier 6) |
| Tier 6 |
|
| Annual drug deductible | $615.00 (excludes Tier 6) |
| Tier 6 |
|
When reviewing Kentucky Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Kentucky that offer similar benefits at similar or lower prices than the plan above. Call 1-855-861-8771 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Kentucky Counties Served
- Adair
- Allen
- Anderson
- Barren
- Bath
- Bell
- Boone
- Bourbon
- Boyle
- Bracken
- Breathitt
- Breckinridge
- Bullitt
- Butler
- Campbell
- Carroll
- Carter
- Casey
- Claiborne
- Clark
- Clay
- Clinton
- Cumberland
- Edmonson
- Elliott
- Estill
- Fayette
- Fleming
- Franklin
- Gallatin
- Garrard
- Grant
- Green
- Greenup
- Harlan
- Harrison
- Hart
- Henry
- Jackson
- Jefferson
- Jessamine
- Johnson
- Kenton
- Knott
- Knox
- Larue
- Lawrence
- Lee
- Leslie
- Letcher
- Lewis
- Lincoln
- Logan
- Magoffin
- Martin
- Mason
- Mccreary
- Meade
- Menifee
- Metcalfe
- Monroe
- Montgomery
- Morgan
- Nelson
- Nicholas
- Ohio
- Owen
- Owsley
- Pendleton
- Perry
- Pickett
- Powell
- Robertson
- Rockcastle
- Rowan
- Russell
- Scott
- Shelby
- Simpson
- Spencer
- Taylor
- Todd
- Trimble
- Warren
- Washington
- Wayne
- Whitley
- Wolfe
- Woodford
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Healthspring, Wellcare, or Kaiser Permanente.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.