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DEVOTED C-SNP CHOICE PREMIUM 009 OK (PPO C-SNP)
The Centers for Medicare & Medicaid Services (CMS) publishes annual Star Ratings that reflect how each Medicare Advantage plan performs across a range of metrics, using a system of one to five stars.
$28.20
Monthly Premium
DEVOTED C-SNP CHOICE PREMIUM 009 OK (PPO C-SNP) is a PPO C-SNP plan offered by Devoted Health
Plan ID: H2845-009
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.
Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.
Learn more about Medicare Advantage plans such as DEVOTED C-SNP CHOICE PREMIUM 009 OK (PPO C-SNP) - H2845-009 by Devoted Health as well as other Medicare Advantage plans available in your area.
$28.20
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $615 |
| Out of Pocket Max |
In-Network: $6000 Out-of-Network: N/A |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $2100 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty Doctor Visit | Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $45 Cost share applies to wound care services, facet injections, cortisol injections, and specialist services. |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $375 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services |
| Urgent Care | Urgent Care: Copayment for Urgent Care $0 to $45 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 $130 Maximum Plan Benefit of $25,000 |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $130 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 $130 Copayment for Worldwide Emergency Transportation (Ground) $340 Maximum Plan Benefit of $25,000 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0 to $340 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 $20% Prior Authorization Required for Air Ambulance Cost share applies per trip. |
Health Care Services and Medical Supplies
DEVOTED C-SNP CHOICE PREMIUM 009 OK (PPO C-SNP) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services Out-of-Network: Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $15 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | Out-of-Network: Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 50% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50% |
| Durable Medical Equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% to 50% Prior Authorization Required for Durable Medical Equipment The max coinsurance applies to the following DME: Medicare-covered ventilator, Bone growth stimulator, Portable oxygen concentrator, Bariatric equipment, Specialty beds, Custom or specialty wheelchairs and scooters, Seat lifts, Specialty brand items, High Frequency Chest Compression Vests, Pain Infusion Pump, and Home Infusion Therapy (HIT) drugs. The min coinsurance applies to all other DME |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Out-of-Network: Diagnostic Procedures/Tests Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0 to $95 Copayment for Medicare Covered Lab Services $0 to $20 Coinsurance for Medicare Covered Lab Services 20% Copayment for Medicare Covered Diagnostic Radiological Services $0 to $300 Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Copayment for Medicare Covered Outpatient X-Ray Services $0 to $75 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, $40 copay all other. Freestanding facility: $40 copay for EKGs/EEGs/ECGs, $40 copay all other. Outpatient hospital: $95 copay for EKGs/EEGs/ECGs, $95 copay all other. No cost share for home sleep studies. No cost share for remote patient monitoring services. |
| 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: $375 per day for days 1 to 5 $0 per day for days 6 to 90 |
| Mental Health Outpatient Care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $45 Copayment for Medicare-covered Group Sessions $45 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $475 Prior Authorization Required for Outpatient Hospital Services The min cost share applies to diagnostic colonoscopies, the max cost share applies to all other outpatient hospital services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $375 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $375 Prior Authorization Required for Ambulatory Surgical Center Services The min cost share applies to diagnostic colonoscopies, the max cost share applies to all other ASC services. |
| Outpatient Substance Abuse Care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $45 Copayment for Medicare-covered Group Sessions $45 Prior Authorization Required for Outpatient Substance Abuse Services Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $45 Copayment for Medicare Covered Group Sessions $45 |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
|
| Podiatry Services | Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $45 In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $45 Copayment for Routine Foot Care $45
|
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $218 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | Out-of-Network: Medicare Covered Preventive Dental: Copayment for Office Visit $45 Prior Authorization Required for Medicare Covered Preventive Dental Non-Medicare Covered Preventive and Comprehensive Dental: Devoted Health will pay as much as $2,000 per year for covered dental services. You pay $0 towards all covered dental services. If you receive dental services from an out-of-network dentist, you will be responsible for paying the difference between the rate we pay the dentist and the rate your dental provider charges, even for services listed as $0. This means you will pay any additional costs above this amount. Covered dental services include, but are not limited to: periodic oral exams, dental evaluations, cleanings, x-rays, fillings, deep cleanings, extractions, dentures, root canals, crowns, and bridges. Please see the Evidence of Coverage for full benefit details. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $45 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 $400 every year |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | Out-of-Network: Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $45 |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | Out-of-Network: Medicare-covered Preventive Services: Copayment for Medicare-covered Preventive Services $0 |
Prescription Drug Costs and Coverage
The DEVOTED C-SNP CHOICE PREMIUM 009 OK (PPO C-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $615 (excludes Tiers 6) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
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| Annual Drug Deductible | $615 (excludes Tiers 6) |
| Select Care Drugs |
|
| Annual Drug Deductible | $615 (excludes Tiers 6) |
| Select Care Drugs |
|
| Annual Drug Deductible | $615 (excludes Tiers 6) |
| Select Care Drugs |
|