Devoted LIBERTY CHOICE Colorado (PPO) H4808-004-0 Plan Details
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*This plan is new and has not yet been rated by CMS.
Devoted LIBERTY CHOICE Colorado (PPO) is a Medicare Advantage plan with prescription drug benefits. Eligibility applies. Enroll online today.
Devoted LIBERTY CHOICE Colorado Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | H4808-004-0 |
| Plan Type: | PPO |
| Plan Year: | 2025 |
| Premium: | $0.00/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 7,900.00 /yr (in-network) |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Not Included |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | See List |
| Insured By: | Devoted Health |
| Summary of Benefits |
|---|
Devoted Health Out-of-Pocket Costs
This Devoted Health Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H4808-004-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | Not Covered |
| Specialist: | $45 Copay |
Emergency, Urgent, and Inpatient Hospital Coverage
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $110 Copay |
| Urgent care: | $45 Copay |
| Ground ambulance: | $350 Copay |
| Inpatient hospital care: | $425.00 per day for days 1 through 4 $0.00 per day for days 5 and beyond |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $214.00 per day for days 21 through 60 $0.00 per day for days 61 and beyond |
Foot Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $45 Copay |
| Routine Foot Care: | Not Covered |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | Not Covered |
| Routine chiropractic: | Not Covered |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $45 Copay |
| Outpatient group therapy: | $45 Copay |
| Inpatient psychiatric hospital care: | $425.00 per day for days 1 through 4 $0.00 per day for days 5 and beyond |
Rehabilitation Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $50 Copay |
| Occupational therapy: | $35 Copay |
Medical Equipment and Supplies
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | Not Covered |
| Durable medical equipment: | 16% Coinsurance Prior Authorization Required |
| Prosthetics: | 20% Coinsurance |
Diagnostics, Lab Services, and Imaging
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $300 Copay Prior Authorization Required |
| Lab services: | $40 Copay Prior Authorization Required |
| Outpatient x-rays: | $75 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | $95 Copay Prior Authorization Required |
Medicare Part B Drugs
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
Dental Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | $45 Copay Prior Authorization Required |
| Oral exam | $0 |
| Dental x-rays | $0 |
| Cleaning | $0 |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
| Maximum dental benefit: | $250.00 (Every year) |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Not Covered |
| Hearing exam | Covered Limits may apply |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam | $ to $45 Copay |
| Routine eye exam | Covered Limits may apply |
| Eyewear benefits | None |
Feel free to download our Devoted LIBERTY CHOICE Colorado Summary of Benefits information.
Prescription Drug Costs & Benefits
This plan does not include a Medicare Part D plan for prescriptions.
CMS 5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) and drug plans (Part D) in several major categories using a 5-star rating system. These ratings are designed to help you understand the quality of care and service you can expect if you join Devoted LIBERTY CHOICE Colorado .
| CMS Measure | Star Rating |
|---|---|
| 2025 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 Availability
Devoted LIBERTY CHOICE Colorado (H4808-004-0) is available in the following locations (click to open):
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
- H4808-001-0: Devoted CHOICE Colorado (PPO)
- H4808-004-0: Devoted LIBERTY CHOICE Colorado (PPO)
- H4808-003-0: Devoted CHOICE GIVEBACK Colorado (PPO)
- H4808-002-0: Devoted CHOICE Colorado (PPO)
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact Devoted Health
| Website: | Devoted Health Plan Page |
|---|---|
| Providers: | Devoted Health Providers Page |
| New Member Health Plan Help: | (800)376-5889 |
| New Member Health Plan TTY: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- Devoted Health, http://www.Devoted.com, Last Accessed February 20, 2024
- Medicare.gov, "Understanding Medicare Advantage Plans", Last Accessed January 21, 2024
- Medicare.gov, "Your Medicare coverage choices", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You in Different Formats", Last Accessed February 19, 2024
- Medicare.gov, "Your Medicare Coverage", Last Accessed April 11, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.