DEVOTED CHOICE MA ONLY 004 CO (PPO) Medicare Advantage Plan H4808-004 • 2027
CMS Rating:
(3.0 out of 5 stars*)
- Monthly Premium
- $0.00Plus Part B premium.
- Medical Deductible
- $200
- Maximum Out-of-Pocket
- $7900.00In-network
- Part B Giveback
- −$166.00 reduction
- Prescription Coverage
- Not Included
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- See List
- Total Enrollment
- 870 beneficiaries
Last update:
DEVOTED CHOICE MA ONLY 004 CO (PPO) Introduction
DEVOTED CHOICE MA ONLY 004 CO is a Medicare Advantage PPO plan offered by Devoted Health. It uses a Preferred Provider Organization (PPO) provider network and comes without prescription drug coverage. For the 2027 plan year it has a $0.00 monthly premium, $200 medical deductible, and $7900.00 in-network maximum out-of-pocket. CMS Plan ID H4808-004 identifies this plan.
Plan Benefits
DEVOTED CHOICE MA ONLY 004 CO has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The tables below detail the most common in-network out-of-pocket expenses for plan H4808-004.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | In-network: $0 copay Out-of-network: $5 copay |
In-network: $0 copay Out-of-network: $5 copay |
| Specialist | In-network: $0-$45 copay Out-of-network: $0-$45 copay |
In-network: $45 copay Out-of-network: $45 copay |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay |
| Telehealth benefit | In-network: $0-$45 copay | In-network: $0-$45 copay |
| Routine chiropractic | Not covered | Not covered |
| Fitness benefits | Coming soon | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Health education | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Counseling services | Not covered | Not covered |
| Over-the-counter drug benefits | Not covered | Not covered |
| Health transportation (non-emergency) | Coming soon | Not covered |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | In-network: $25-$300 copay Out-of-network: $25-$300 copay |
In-network: $0-$300 copay Out-of-network: $0-$300 copay |
| Lab services | In-network: $0-$60 copay Out-of-network: $0-$60 copay |
In-network: $0-$40 copay Out-of-network: $0-$40 copay, 20% coinsurance |
| Outpatient x-rays | In-network: $0-$75 copay Out-of-network: $0-$75 copay |
In-network: $0-$75 copay Out-of-network: $0-$75 copay |
| Diagnostic tests and procedures | In-network: $0-$95 copay Out-of-network: $0-$95 copay |
In-network: $0-$95 copay Out-of-network: $0-$95 copay |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | $115 copay | $115 copay |
| Worldwide emergency care | Coming soon | $115 copay |
| Urgent care | $0-$40 copay | $0-$40 copay |
| Inpatient hospital care | In-network: Tier 1 $425 per day for days 1-4 $0 per day for days 5-90 $0 per stay Out-of-network: $425 per day for days 1-4 $0 per day for days 5-90 $0 per stay |
In-network: Tier 1 $425 per day for days 1-4 $0 per day for days 5-90 $0 per stay Out-of-network: $425 per day for days 1-4 $0 per day for days 5-90 $0 per stay |
| Skilled Nursing Facility | In-network: Tier 1 $0 per day for days 1-20 $221 per day for days 21-100 Out-of-network: 40% per stay |
In-network: Tier 1 $0 per day for days 1-20 $218 per day for days 21-100 Out-of-network: 20% per stay |
| Ground ambulance | In-network: $0-$350 copay Out-of-network: $0-$350 copay |
In-network: $0-$350 copay Out-of-network: $0-$350 copay |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | In-network: $45 copay Out-of-network: $45 copay |
In-network: $45 copay Out-of-network: $45 copay |
| Outpatient group therapy | In-network: $45 copay Out-of-network: $45 copay |
In-network: $45 copay Out-of-network: $45 copay |
| Inpatient psychiatric hospital care | In-network: Tier 1 $425 per day for days 1-4 $0 per day for days 5-90 $0 per stay Out-of-network: $425 per day for days 1-4 $0 per day for days 5-90 $0 per stay |
In-network: Tier 1 $425 per day for days 1-4 $0 per day for days 5-90 $0 per stay Out-of-network: $425 per day for days 1-4 $0 per day for days 5-90 $0 per stay |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | In-network: $0-$50 copay Out-of-network: $0-$50 copay |
In-network: $45-$50 copay Out-of-network: $45-$50 copay |
| Occupational therapy | In-network: $0-$35 copay Out-of-network: $0-$35 copay |
In-network: $35 copay Out-of-network: $35 copay |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: 0%-18% coinsurance Out-of-network: 20% coinsurance |
| Durable medical equipment | In-network: 20% coinsurance Out-of-network: 50% coinsurance |
In-network: 18% coinsurance Out-of-network: 20% coinsurance |
| Prosthetics | In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | In-network: 0%-20% coinsurance Out-of-network: 40% coinsurance |
In-network: 0%-20% coinsurance Out-of-network: 40% coinsurance |
| Other Part B drugs (Medicare-covered) | In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Dental x-rays | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Cleaning | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Periodontics | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Endodontics | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
In-network: 0%-50% coinsurance Out-of-network: 0%-50% coinsurance |
| Restorative services | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
In-network: 0%-50% coinsurance Out-of-network: 0%-50% coinsurance |
| Implant services | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
Not covered |
| Orthodontics | Not covered | Not covered |
| Oral/Maxillofacial surgery | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Contact lenses | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass frames only | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass lenses only | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Eyeglasses (frames & lenses) | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Upgrades | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | In-network: $0 copay Out-of-network: $35 copay |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Fitting/evaluation | In-network: $0 copay Out-of-network: $35 copay |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Prescription hearing aids | In-network: $599-$899 copay Out-of-network: 90% coinsurance |
In-network: $599-$899 copay Out-of-network: $599-$899 copay |
| OTC hearing aids | Not covered | Not covered |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Not covered | Not covered |
| Home-based palliative care | Not covered | Not covered |
| Personal emergency response system | Coming soon | Not covered |
| Weight management programs | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Wigs for chemotherapy-related hair loss | Coming soon | Not covered |
| Alternative therapies | In-network: 0%-50% coinsurance Out-of-network: 0%-50% coinsurance |
In-network: 0%-50% coinsurance Out-of-network: 0%-50% coinsurance |
| Massage therapy | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
In-network: 50% coinsurance Out-of-network: 50% coinsurance |
| Home/bathroom safety devices | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 20% coinsurance |
Certain preventive services are covered 100% by DEVOTED CHOICE MA ONLY 004 CO as a Part B benefit.
Prescription Drug Coverage
This plan does not include a Medicare Part D plan for prescriptions.
CMS 5-Star Performance Ratings (Contract ID: H4808)
Medicare Advantage (Part C) and Part D plans are rated each year by CMS on a 5-star scale. Ratings summarize plan performance across clinical care and member experience measures.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | Not enough data available |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Contact Information for Devoted Health
- Website
- Devoted Health Plan Page
- Providers
- Devoted Health Providers Page
- Formulary
- Devoted Health Formulary Page
- Pharmacy
- Devoted Health Pharmacy Page
- New Member Health Plan Help
- (844)978-2770
- New Member Health Plan TTY
- 711
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Plan Availability
DEVOTED CHOICE MA ONLY 004 CO (H4808-004-0) is available in the following locations:
Frequently Asked Questions
Here are some of the most frequently asked questions about this plan (click to open).
Frequently Asked Questions About DEVOTED CHOICE MA ONLY 004 CO (PPO)
How much does plan H4808-004 cost per month?
The plan’s monthly premium is $0.00 for 2027. The Part B premium is not included.
What is the annual out-of-pocket maximum (MOOP) for this plan?
The annual in-network MOOP is $7900.00 for 2027. After this limit is reached, covered in-network services are fully paid.
How many beneficiaries are enrolled in this plan?
CMS reports 870 beneficiaries enrolled in this plan.
What is the prescription drug deductible for 2027?
For 2027, the prescription drug deductible is $0.00.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Devoted Health (official source) | http://www.Devoted.com | October 4, 2026 |
| Medicare.gov | Understanding Medicare Advantage Plans | 25 May, 2025 |
| NCOA.org | 5 Steps to Choosing the Right Medicare Plan for You | 25 May, 2025 |
| Medicare.gov | Explore your Medicare coverage options | 25 May, 2025 |
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