DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 026 MO (PPO C-SNP)
Available to residents of Livingston County, MO for 2027. Contract H4030, plan 026, segment 0.
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- Rx cost-sharing for all pharmacies and tiers
- Other plans in Livingston County
- Plan website
- Browse the DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 026 MO (PPO C-SNP) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
New for 2027. This plan has no 2026 predecessor in the CMS crosswalk. Every MO plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | $110.00 a month?You must continue to pay your Medicare Part B premium. |
| In-network out-of-pocket maximum | $5,700.00? |
| In- and out-of-network out-of-pocket maximum | $8,800.00 |
| Drug deductible | $700.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | PPO C-SNP? |
| Special needs plan | Chronic-condition SNP |
| Qualifying condition | CardiovascularDisorders,ChronicHeartFailure,DiabetesMellitus |
| Contract / plan | H4030-026-0 |
| Offered by | Devoted Health |
| Parent organization | Devoted Health, Inc. |
| Formulary tiers | 5 |
| Formulary exception tier | 4? |
| Pharmacy search | www.devoted.com |
| Member services | (844)978-2770TTY 711 |
CMS star ratings
- Overall
- —
- Health plan (Part C)
- —
- Drug plan (Part D)
- —
Published per contract — every plan under contract H4030 shares this rating.
Plan health benefits
| Service | In-network | Out-of-network? |
|---|---|---|
| Doctor visits | ||
| Primary care doctor | $0 copay | $5 copay |
| Specialist | $40 copay(authorization required) | $40 copay |
| Other health care professional | $0–$40 copay(authorization required) | $0–$40 copay |
| Additional telehealth services | $0–$50 copay | — |
| Preventive care | ||
| Medicare-covered preventive services | $0 copay | $0 copay |
| Annual physical exam | $0 copay | $0 copay |
| Kidney disease education | $0 copay | $0 copay |
| Glaucoma screening | $0 copay | $0 copay |
| Diabetes self-management training | $0 copay | $0 copay |
| Diagnostic tests, labs and imaging | ||
| Diagnostic tests and procedures | $0–$95 copay(authorization required) | $0–$95 copay |
| Lab services | $0–$40 copay; 20% coinsurance(authorization required) | $0–$40 copay; 20% coinsurance |
| Diagnostic radiology (e.g. MRI, CT) | $25–$300 copay(authorization required) | $25–$300 copay |
| Therapeutic radiology | 20% coinsurance(authorization required) | 40% coinsurance |
| Outpatient x-rays | $0–$75 copay(authorization required) | $0–$75 copay |
| Emergency and urgent care | ||
| Emergency room | $130 copay | — |
| Urgent care | $0–$50 copay | — |
| Worldwide emergency coverage | $130 copay · $25,000 plan limit | — |
| Worldwide urgent care | $130 copay · $25,000 plan limit | — |
| Worldwide emergency transportation | $325 copay; 20% coinsurance | — |
| Hospital care | ||
| Inpatient hospital stay | $550 per day for days 1–5; $0 per day for days 6–90(authorization required) | $550 per day for days 1–5; $0 per day for days 6–90 |
| Outpatient hospital services | $0–$530 copay(authorization required) | $0–$530 copay |
| Outpatient observation | $430 copay(authorization required) | $430 copay |
| Ambulatory surgical center | $0–$430 copay(authorization required) | $0–$430 copay |
| Outpatient blood services | $0 copay(authorization required) | $0 copay |
| Skilled nursing and home health | ||
| Skilled nursing facility | $10 per day for days 1–20; $221 per day for days 21–100(authorization required) | 40% coinsurance per stay |
| Home health care | $0 copay(authorization required) | 40% coinsurance |
| Kidney dialysis | 20% coinsurance(authorization required) | 20% coinsurance |
| Rehabilitation | ||
| Occupational therapy | $40–$50 copay(authorization required) | $40–$50 copay |
| Physical therapy and speech-language therapy | $40–$50 copay(authorization required) | $40–$50 copay |
| Cardiac rehabilitation | $40 copay(authorization required) | $40 copay |
| Pulmonary rehabilitation | $35 copay(authorization required) | $35 copay |
| Mental health and substance use | ||
| Inpatient psychiatric hospital stay | $430 per day for days 1–5; $0 per day for days 6–90(authorization required) | $430 per day for days 1–5; $0 per day for days 6–90 |
| Outpatient mental health, individual session | $40 copay(authorization required) | $40 copay |
| Outpatient mental health, group session | $40 copay(authorization required) | $40 copay |
| Psychiatrist, individual session | $40 copay(authorization required) | $40 copay |
| Psychiatrist, group session | $40 copay(authorization required) | $40 copay |
| Partial hospitalization | $80 copay(authorization required) | $80 copay |
| Intensive outpatient program | $80 copay(authorization required) | $80 copay |
| Outpatient substance use, individual session | $40 copay(authorization required) | $40 copay |
| Outpatient substance use, group session | $40 copay(authorization required) | $40 copay |
| Opioid treatment program | $40 copay(authorization required) | $40 copay |
| Ambulance and transportation | ||
| Ground ambulance | $0–$325 copay(authorization required) | $0–$325 copay |
| Air ambulance | 20% coinsurance(authorization required) | 20% coinsurance |
| Transportation to plan-approved locations | Not covered | — |
| Medical equipment and supplies | ||
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20%–50% coinsurance(authorization required) | 50% coinsurance |
| Prosthetics (e.g. braces, artificial limbs) | 0%–20% coinsurance(authorization required) | 0%–40% coinsurance |
| Medical supplies | 0%–20% coinsurance(authorization required) | 0%–40% coinsurance |
| Diabetes supplies | $0 copay(authorization required) | 50% coinsurance |
| Diabetic therapeutic shoes or inserts | $0 copay(authorization required) | 50% coinsurance |
| Chiropractic, acupuncture and foot care | ||
| Chiropractic (Medicare-covered) | $15 copay(authorization required) | $15 copay |
| Routine chiropractic care | Not covered | — |
| Acupuncture | Not covered | — |
| Foot exams and treatment (Medicare-covered) | $40 copay(authorization required) | $40 copay |
| Routine foot care | $40 copay(authorization required, limits apply) | $40 copay |
| Dental? | ||
| Medicare-covered dental services | $40 copay(authorization required) | $40 copay |
| Preventive dental plan limit | $4,000 plan limit every year | — |
| Oral exams | $0 copay(limits apply) | $0 copay |
| Cleanings | $0 copay(limits apply) | $0 copay |
| Fluoride treatment | $0 copay(limits apply) | $0 copay |
| Dental x-rays | $0 copay(limits apply) | $0 copay |
| Other diagnostic dental services | Not covered | — |
| Other preventive dental services | Not covered | — |
| Restorative services (fillings, crowns) | 50% coinsurance(limits apply) | 50% coinsurance |
| Endodontics (root canals) | 50% coinsurance(limits apply) | 50% coinsurance |
| Periodontics (gum disease) | 50% coinsurance(limits apply) | 50% coinsurance |
| Dentures and other removable prosthodontics | 50% coinsurance(limits apply) | 50% coinsurance |
| Maxillofacial prosthetics | Not covered | — |
| Implants | 50% coinsurance(limits apply) | 50% coinsurance |
| Bridges and other fixed prosthodontics | 50% coinsurance(limits apply) | 50% coinsurance |
| Oral and maxillofacial surgery | 50% coinsurance(limits apply) | 50% coinsurance |
| Orthodontics | Not covered | — |
| Adjunctive general services | 50% coinsurance(limits apply) | 50% coinsurance |
| Vision? | ||
| Eye exam (Medicare-covered) | $0–$40 copay(authorization required) | $0–$40 copay |
| Routine eye exam | $0 copay(authorization required, limits apply) | $0 copay |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) | — |
| Eyewear plan limit | $350 plan limit every year | — |
| Contact lenses | $0 copay(limits apply) | $0 copay |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) | $0 copay |
| Eyeglass lenses | $0 copay(limits apply) | $0 copay |
| Eyeglass frames | $0 copay(limits apply) | $0 copay |
| Eyewear upgrades | $0 copay(limits apply) | $0 copay |
| Hearing? | ||
| Hearing exam (Medicare-covered) | $40 copay(authorization required) | $40 copay |
| Routine hearing exam | $0 copay(authorization required, limits apply) | $35 copay |
| Hearing aid fitting and evaluation | $0 copay(authorization required) | $35 copay |
| Hearing aids (all types) | $599–$899 copay(limits apply) | 90% coinsurance |
| Hearing aids, inner ear | Not covered | — |
| Hearing aids, outer ear | Not covered | — |
| Hearing aids, over the ear | Not covered | — |
| Medicare Part B drugs | ||
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) | 40% coinsurance |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 40% coinsurance |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 0%–40% coinsurance |
| Other extra benefits? | ||
| Over-the-counter (OTC) allowance | $77 allowance every three months | — |
| Meals after a hospital stay or for a chronic condition | Not covered | — |
| Fitness benefit | $0 copay | 0%–90% coinsurance |
| Health education | $0 copay | $0 copay |
| Nutritional / dietary benefit | $0 copay | $0 copay |
| Extra smoking and tobacco cessation counseling | Not covered | — |
| Enhanced disease management | Not covered | — |
| Telemonitoring | Not covered | — |
| Remote access technologies (web/phone, nurse line) | Not covered | — |
| Home and bathroom safety devices | $0 copay | 50% coinsurance |
| Counseling services | Not covered | — |
| In-home safety assessment | Not covered | — |
| Personal emergency response system (PERS) | Not covered | — |
| Medical nutrition therapy | Not covered | — |
| Post-discharge in-home medication reconciliation | Not covered | — |
| Re-admission prevention | Not covered | — |
| Wigs for hair loss from chemotherapy | Not covered | — |
| Weight management programs | $0 copay | $0 copay |
| Alternative therapies | $0 copay | $0 copay |
| Therapeutic massage | Not covered | — |
| Adult day health services | Not covered | — |
| Home-based palliative care | Not covered | — |
| In-home support services | Not covered | — |
| Support for caregivers | Not covered | — |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2027). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $2.00 |
| Tier 3 · Preferred Brand | 25% |
| Tier 4 · Non-Preferred Drug | 25% |
| Tier 5 · Specialty Tier | 25% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $2.00 | $2.00 | $2.00 | $6.00 | $6.00 | $5.00 |
| Tier 3: Preferred Brand | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 4: Non-Preferred Drug | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | n/a | n/a | n/a |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Also available in 24 other MO counties
Benefits in plain text
DEVOTED C-SNP CHOICE GIVEBACK EXTRAS 026 MO (PPO C-SNP) (H4030-026-0) is a 2027 PPO C-SNP Medicare Advantage plan offered by Devoted Health, available to residents of Livingston County, MO.
The monthly premium is $0.00.
The plan reduces the member's Medicare Part B premium by $110.00 a month (a "giveback"); the Part B premium itself must still be paid.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
Its in-network out-of-pocket maximum is $5,700.00.
The combined in- and out-of-network out-of-pocket maximum is $8,800.00.
The drug deductible is $700.00. Tier 1 and 2 exempt.
It is a special needs plan (Chronic-condition SNP).
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $2.00; tier 3 (Preferred Brand): 25%; tier 4 (Non-Preferred Drug): 25%; tier 5 (Specialty Tier): 25%.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.