DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP)
H5718-004 • 2026 • Boyle County, KY
DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) H5718-004 • 2026 • Boyle County, KY
DEVOTED C-SNP CHOICE PLUS 004 KY is a Medicare Chronic or Disabling Condition plan offered by Devoted Health for the 2026 plan year. It is identified by CMS Plan ID H5718-004 and serves individuals who meet defined eligibility criteria.
DEVOTED C-SNP CHOICE PLUS 004 KY Overview
Plan Overview for H5718-004-0 | |
|---|---|
| CMS Plan ID: | H5718-004-0 |
| Plan Type: | PPO C-SNP |
| Plan Year: | 2026 |
| Monthly Premium: | $38.40 Plus your Medicare Part B premium. |
| Medical Deductible: | $990 |
| Maximum Out-of-Pocket: | $9250.00 (In-Network) |
| Part B Give Back: | Not offered |
| Prescription Drug Coverage: | Basic, $615.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Service Area: | Boyle County, KY |
| Enrollment (Nationwide) | 952 beneficiaries |
| Enrollment (CMS – Local) | 0 beneficiaries in Boyle County |
| Provided By: | Devoted Health |
Plan Overview and Eligibility
- DEVOTED C-SNP CHOICE PLUS 004 KY is a Chronic Condition Special Needs Plan (C-SNP) designed for people with qualifying health conditions.
- Eligibility requires Medicare Part A and Part B and residence in Boyle County.
- The plan operates on a PPO network and includes Medicare Part D drug coverage. The annual Part D deductible is $615.00.
- It includes all standard Medicare benefits, along with plan-specific coverage enhancements.
- Cost-sharing may differ from Original Medicare depending on the service used.
This plan uses a Preferred Provider Organization (PPO) network, allowing you to see providers both inside and outside the network. Costs are typically lower when using in-network providers, and referrals are not usually needed for specialist care. Emergency care and out-of-area dialysis are covered.
Covered Services and Cost Structure
This section outlines in-network costs for primary care and specialist office visits, along with related preventive services.
| Covered Service | In-Network Cost |
|---|---|
| Primary: | In-network: $0 copay | Out-of-network: 40% coinsurance |
| Specialist: | In-network: 30% coinsurance | Out-of-network: 40% coinsurance |
This section outlines in-network costs for preventive and wellness services included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Annual wellness exam: | In-network: $0 copay |
| Telehealth benefit: | In-network: 0%-30% coinsurance |
| Routine chiropractic: | Not covered |
| Fitness benefits: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Health education: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Counseling services: | Not covered |
| Over-the-counter drug benefits: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Health transportation (non-emergency): | Not covered |
This section outlines in-network costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Covered Service | In-Network Cost |
|---|---|
| Diagnostic radiology services: | In-network: 50% coinsurance | Out-of-network: 50% coinsurance |
| Lab services: | In-network: 50% coinsurance | Out-of-network: 50% coinsurance |
| Outpatient x-rays: | In-network: 50% coinsurance | Out-of-network: 50% coinsurance |
| Diagnostic tests and procedures: | In-network: 0%-50% coinsurance | Out-of-network: 0%-50% coinsurance |
This section outlines in-network costs for emergency services, urgent care, ambulance transportation, inpatient hospital stays, and skilled nursing facility care.
| Covered Service | In-Network Cost |
|---|---|
| Emergency room care: | $115 copay |
| Worldwide emergency care: | $0 copay |
| Urgent care: | 0%-20% coinsurance |
| Inpatient hospital care: | In-network: | Tier 1 | $2,230 per stay | Out-of-network: | 40% per stay |
| Skilled Nursing Facility: | In-network: | Tier 1 | $0 per day for days 1-20 | $218 per day for days 21-100 | Out-of-network: | 40% per stay |
| Ground ambulance: | In-network: 0%-50% coinsurance | Out-of-network: 0%-50% coinsurance |
This section outlines in-network costs for mental health services, including outpatient therapy and inpatient psychiatric care.
| Covered Service | In-Network Cost |
|---|---|
| Outpatient individual therapy: | In-network: 30% coinsurance | Out-of-network: 40% coinsurance |
| Outpatient group therapy: | In-network: 30% coinsurance | Out-of-network: 40% coinsurance |
| Inpatient psychiatric hospital care: | In-network: | Tier 1 | $2,230 per stay | Out-of-network: | 40% per stay |
This section outlines in-network costs for rehabilitation services, including physical therapy, speech and language therapy, and occupational therapy.
| Covered Service | In-Network Cost |
|---|---|
| Physical therapy and speech and language therapy: | In-network: 30% coinsurance | Out-of-network: 40% coinsurance |
| Occupational therapy: | In-network: 30% coinsurance | Out-of-network: 40% coinsurance |
This section outlines in-network costs for medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Covered Service | In-Network Cost |
|---|---|
| Diabetes supplies: | In-network: 20% coinsurance | Out-of-network: 50% coinsurance |
| Durable medical equipment: | In-network: 20% coinsurance | Out-of-network: 50% coinsurance |
| Prosthetics: | In-network: 0%-20% coinsurance | Out-of-network: 0%-50% coinsurance |
This section outlines in-network cost sharing for chemotherapy and other Medicare Part B-covered drugs.
| Covered Service | In-Network Cost |
|---|---|
| Chemotherapy: | In-network: 0%-20% coinsurance | Out-of-network: 50% coinsurance |
| Other Part B drugs (Medicare-covered): | In-network: 0%-20% coinsurance | Out-of-network: 0%-50% coinsurance |
This section outlines in-network cost sharing for dental services, including preventive care, exams, x-rays, cleanings, and comprehensive dental procedures.
| Covered Service | In-Network Cost |
|---|---|
| Oral exam: | 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 |
| Cleaning: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Periodontics: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Endodontics: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Restorative services: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Implant services: | Not covered |
| Orthodontics: | Not covered |
| Oral/Maxillofacial surgery: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
This section outlines in-network cost sharing for vision services, including eye exams, eyeglasses, and contact lenses.
| Covered Service | In-Network Cost |
|---|---|
| Routine eye exam: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Contact lenses: | 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 |
| Eyeglass lenses only: | 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 |
| Upgrades: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
This section outlines in-network cost sharing for hearing-related services, including exams, fittings, and hearing aids.
| Covered Service | In-Network Cost |
|---|---|
| Hearing exam: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Fitting/evaluation: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Prescription hearing aids: | In-network: $399-$699 copay | Out-of-network: $399-$699 copay |
| OTC hearing aids: | Not covered |
This section outlines in-network cost sharing for additional and special needs services that may be included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Adult day health services: | Not covered |
| Home-based palliative care: | Not covered |
| Personal emergency response system: | Not covered |
| Weight management programs: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Wigs for chemotherapy-related hair loss: | Not covered |
| Alternative therapies: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Massage therapy: | Not covered |
| Home/bathroom safety devices: | In-network: $0 copay | Out-of-network: 50% coinsurance |
Prescription Drug Plan Costs & Benefits
Prescription Drug Plan Premium
The following table outlines the prescription drug plan premium details of this plan.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | $38.40 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $38.40 |
| Low Income Premium Subsidy: | $38.44 |
| Low Income Premium Subsidy CMS Pays: | $38.40 |
| Low Income Subsidy Premium: | $0.00 |
For more information about the Low Income Subsidy, refer to the Social Security Extra Help page.
Drug Plan Deductible
The prescription drug annual deductible with this plan is $615.00. This is the amount you must pay at the pharmacy before Devoted Health begins paying its share.
Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and drug plan deductible, DEVOTED C-SNP CHOICE PLUS 004 KY has costs that you must pay out-of-pocket when you pick up your prescriptions. The following table details those costs by formulary tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $18.00 copay | Coming soon |
| Generic | $19.00 copay | Coming soon |
| Preferred Brand | 25% coinsurance | Coming soon |
| Non-Preferred Drug | 31% coinsurance | Coming soon |
| Specialty Tier | 25% coinsurance | Coming soon |
| Select Care Drugs | $0.00 copay | Coming soon |
| *Deductible does not apply. | ||
Plan Star Ratings
Medicare assigns star ratings to plans based on quality and performance across multiple measures, including customer service, member experience, and health outcomes. Ratings are updated annually by the Centers for Medicare & Medicaid Services (CMS) and are shown on a 1 to 5 star scale, with 5 stars representing the highest quality.
CMS Star Ratings for Plan H5718-004-0 – 2026
| CMS Measure | Star Rating (out of 5) |
|---|---|
| 2026 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | Plan too new to be measured |
| Managing Chronic (Long Term) Conditions | Plan too new to be measured |
| Member Experience with Health Plan | Plan too new to be measured |
| Complaints and Changes in Plans Performance | Plan too new to be measured |
| Health Plan Customer Service | Plan too new to be measured |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | Plan too new to be measured |
| Member Experience with the Drug Plan | Plan too new to be measured |
| Drug Safety and Accuracy of Drug Pricing | Plan too new to be measured |
Contact Information for Devoted Health
| Contact Type | Details |
|---|---|
| Website: | Devoted Health Plan Page |
| New Members: | 1-844-978-2770 |
| Existing Members: | 1-800-338-6833 |
| Plan Address: | Devoted Health | PO Box 211037 | Eagan, MN 55121 |
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at medicare.gov.
- CMS.gov, Landscape Source Files — Last accessed May 2, 2026
- CMS.gov, Medicare Part C & D Performance — Last accessed May 2, 2026
- CMS.gov, Plan Benefits Package — Last accessed May 2, 2026
- CMS.gov, Monthly Enrollment by Contract/Plan/State/County — Last accessed May 2, 2026
Data sources and methodology documentation.
- Devoted Health (official source), http://www.Devoted.com — Last accessed April 30, 2026
- CMS.gov, "Chronic Condition Special Needs Plans (C-SNPs)" — Last accessed April 28, 2026
- Medicare.gov, "Understanding Medicare Advantage Plans" — Last accessed April 28, 2026
- NCOA.org, "5 Steps to Choosing the Right Medicare Plan for You" — Last accessed April 28, 2026
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