Back to results
Medicare Advantage · Local PPO
Devoted Health
Plan year 2026

DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) H7355-004

Monthly premium
$23.80
+ your Part B premium
Max out-of-pocket
$5,400
in-network annual cap
Primary care
$0
per visit copay
Specialist
$35
per visit
Eligibility required for this D-SNP
You must be entitled to Medicare Part A, enrolled in Part B, and have a Medicaid category this plan accepts. The plan must verify your Medicaid status. Eligibility alone does not create a year-round right to enroll.
Integration status
CO
Common dual-eligibility labels

These definitions are educational. They do not confirm which Medicaid categories this specific plan accepts.

FBDE
Full Medicaid benefits in addition to Medicare.
QMB+
QMB help with Medicare costs plus full Medicaid benefits.
SLMB+
SLMB help with the Part B premium plus full Medicaid benefits.
QMB
Help with Medicare premiums and Medicare-covered cost sharing.
Check the Summary of Benefits or Evidence of Coverage for the exact Medicaid levels this plan accepts.
Could a Medicare Savings Program help?

Medicare Savings Programs are run by each state. The 2026 federal baseline monthly income limits are:

  • QMB: $1,350 for one person or $1,824 for a married couple
  • SLMB: $1,616 for one person or $2,184 for a married couple
  • QI: $1,816 for one person or $2,455 for a married couple
Alaska, Hawaii, and some states use different limits or resource rules. Qualifying for an MSP does not by itself confirm eligibility for this D-SNP. Apply through your state Medicaid office.
Learn about QMB, SLMB, and QI

Your costs at a glanceIn-network, for the 2026 plan year

Rx deductible
$615
Inpatient hospital
Days 1-9: $275/day, Days 10-90: $0/day
no limit on covered hospital days
Inpatient mental health
Days 1-8: $275/day, Days 9-90: $0/day
Outpatient surgery
$0
–$375
Emergency room
$130
Urgent care
$0
–$45

Your Medicare cost sharing may be lower depending on your category of Medicaid eligibility.

What's included, and what it's actually worth5 benefits included. Tap any card for the detail

Dental

$2,000/yr allowance
Annual max$2,000/yr allowance
This is a supplemental benefit with plan-specific limits. See plan documents for details.

Hearing

$399–$699copay per hearing aid
Details$399–$699 copay per hearing aid
This is a supplemental benefit with plan-specific limits. See plan documents for details.

Vision

$375/yr eyewear allowance
Eyewear allowance$375/yr eyewear allowance
This is a supplemental benefit with plan-specific limits. See plan documents for details.

OTC allowance

$50/quarter OTC allowance
Prepaid card$50/quarter OTC allowance
See more details about this plan
Doctor Visits: PCP$0 copay
In-network$0 copay per visit
Doctor Visits: Specialist$35 copay
In-network$35 copay per visit
Inpatient Hospital$275/day, days 1–9
In-networkDays 1-9: $275/day, Days 10-90: $0/day
Benefit limitNone — additional covered days are unlimited
Outpatient Surgery$0–$375
In-network$0–$375 per procedure
Mental HealthDays 1-8: $275/day, Days 9-90: $0/day
Inpatient psychiatricDays 1-8: $275/day, Days 9-90: $0/day
MealsMeal benefit

Your coverageCheck your coverageFrom the doctors and prescriptions you added

Your plan's drug tiers30-day retail · after any applicable deductible

Tier 1
25%
Preferred Generic
Tier 2
25%
Generic
Tier 3
25%
Preferred Brand· after deductible
Tier 4
25%
Non-Pref Brand· after deductible
Tier 5
25%
Specialty· after deductible
Tier 6
$0
Tier 6· after deductible

Our take

Where this plan shines

This plan’s out-of-pocket maximum is below the national median.
See your primary doctor for $0.

Things to know before you enroll

Limited coverage while traveling outside the plan’s service area.
Questions? Talk to a licensed agent at1-866-764-3312 (TTY: 711)

Plan documents

Summary of Benefits (PDF)
Download the plan's official Summary of Benefits document
Evidence of Coverage (PDF)
Complete plan details and rules
Check Your Doctors
See if your doctors accept this plan
Documentos en español
Llame al (844)978-2770 (TTY: 711) para solicitar documentos en español

Helpful next steps

The Pocket Protector · NPN 21126942 · 1-866-764-3312 (TTY: 711) · thepocketprotector.com

Plan benefits, premiums, and copays may vary by county and plan. You must continue to pay your Medicare Part B premium. Benefits and costs may vary by service area. Contact the plan or CMS for complete details.

We do not offer every plan available in your area. Currently we represent a limited number of organizations which offer a limited number of products in your area. Please contact Medicare.gov, 1-800-MEDICARE (TTY: 1-877-486-2048), or your local State Health Insurance Program (SHIP) to get information on all of your options.

Members may receive a monthly or quarterly allowance in the form of a benefits prepaid card to pay for a wide range of plan-approved items. Unused amounts will expire at the end of the month or quarter.

Out-of-network/non-contracted providers are under no obligation to treat plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you to contact the plan.

Dental, hearing, vision, and other supplemental benefits may have limitations and restrictions. These benefits vary by plan. Please refer to the plan's Evidence of Coverage for details.

The plan formulary, pharmacy network, and/or copays may change at any time. You will receive notice when necessary.

To join a Dual Eligible Special Needs Plan (D-SNP), you must be entitled to Medicare Part A, enrolled in Medicare Part B, and receive full Medicaid benefits or assistance from your state. Eligibility requirements vary by state and may require further verification. Enrollment in the plan depends on contract renewal.

Membership in this plan depends on your continued Medicaid eligibility. If you lose your Medicaid eligibility, you may be disenrolled from this plan. Contact your state Medicaid office or 1-800-MEDICARE (TTY: 1-877-486-2048) for more information.

Benefits shown are based on CMS public plan data. Actual benefits vary by county. Not all plans available in all areas. Speak with a licensed agent before enrolling.

  1. The Pocket Protector represents Medicare Advantage HMO, PPO, and PFFS organizations and stand-alone PDP prescription drug plans that have a Medicare contract. Enrollment depends on the plan's contract renewal.
  2. The Pocket Protector is not connected with or endorsed by the United States government or the federal Medicare program.

Privacy Policy

DEVOTED DUAL CHOICE 004 MS (PPO D-SNP) - Devoted Health | The Pocket Protector