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DEVOTED CHOICE GIVEBACK EXTRAS 005 MO (PPO) (2027)

Medicare Advantage plan with drug coverage from Devoted Health, plan ID H4030-005-000. Sold in 25 counties in Missouri.

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2027 costs

Monthly premium$0
Drug deductible$700
Medical deductible$150
Out-of-pocket maximum (in network)$5,450
Plan typeMedicare Advantage plan with drug coverage, PPO
Referral needed to see a specialistNo
Plan IDH4030-005-000

With a Medicare Advantage plan you also keep paying your Medicare Part B premium.

What this plan would cost for your prescriptions

Add your prescriptions to see this plan's estimated yearly cost for them, which of them are on its drug list, and how each compares with Cost Plus Drugs prices.

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What you pay for medical care

Primary care visit$0
Specialist visit$40
Preventive care$0
Urgent care$0–$50
Emergency room$130
Hospital stay$550/day
Outpatient surgery$0–$530
Lab tests$0–$95
X-rays and scans$25
Mental health visit$40
Physical therapy$40–$50
Medical equipment20%
TelehealthCovered

In-network amounts. A range means it depends on the service or provider.

Extra benefits

DentalCovered — up to $4000 allowance
VisionCovered — up to $350/yr allowance
HearingCovered — $599–$899 copay per aid
Over-the-counter itemsCovered — up to $100/quarter allowance
FitnessCovered
Rides to appointmentsNot covered

Drug costs by tier

Tier30 days, standard pharmacy30 days, preferred pharmacy90 days by mail
1 Preferred Generic$0$0$0
2 Generic$2$2$5
3 Preferred Brand25%25%25%
4 Non-Preferred Drug25%25%25%
5 Specialty Tier25%25%N/A

A percentage is coinsurance: your share of the drug's price. The drug deductible may apply first, depending on the tier. Your Part D out-of-pocket costs are capped at $2,400 for 2027.

Where it's sold

Missouri (25 counties)

Other 2027 Devoted Health plans in Missouri

Plan costs and benefits are from CMS's 2027 Medicare plan data (data as of October 27, 2026). Star ratings are CMS's 2027 Star Ratings. Every year, Medicare evaluates plans based on a 5-star rating system. Benefits, premiums and copays can change from year to year; check the plan's Evidence of Coverage, call the plan, or use Medicare.gov before you enroll.