DEVOTED CHOICE 004 HI (PPO)
$0.00 /month
Monthly Premium
Among the lowest-premium plans in 2026
$370.00
Annual Deductible
995
Drugs Covered
1
States Served
Top Covered Drugs
Most popular medications covered by this plan, ordered by national search frequency. Click any drug to see exact copay, restrictions, and alternatives.
| # | Drug Name | Type | Tier | 30-Day Copay | |
|---|---|---|---|---|---|
| 1 | Haloperidol | Brand | Tier 3 | $0.00 | Details |
| 2 | Lorbrena lorlatinib | Brand | Tier 5 | $0.00 | Details |
| 3 | Venlafaxine Hydrochloride | Brand | Tier 3 | $0.00 | Details |
| 4 | Cefuroxime | Brand | Tier 3 | $0.00 | Details |
| 5 | Levothyroxine Sodium levothyroxine sodium | Brand | Tier 1 | $0.00 | Details |
| 6 | Vizimpro dacomitinib | Brand | Tier 5 | $0.00 | Details |
| 7 | POSACONAZOLE Posaconazole | Brand | Tier 5 | $0.00 | Details |
| 8 | Buspirone Hydrochloride | Brand | Tier 1 | $0.00 | Details |
| 9 | Ampicillin and Sulbactam | Brand | Tier 4 | $0.00 | Details |
| 10 | RECOMBIVAX HB Hepatitis B Vaccine (Recombinant) | Brand | Tier 1 | $0.00 | Details |
| 11 | Augtyro repotrectinib | Brand | Tier 5 | $0.00 | Details |
| 12 | Morphine Sulfate | Brand | Tier 3 | $0.00 | Details |
| 13 | REYATAZ ATAZANAVIR | Brand | Tier 5 | $0.00 | Details |
| 14 | Dexamethasone | Brand | Tier 3 | $0.00 | Details |
| 15 | ZYKADIA ceritinib | Brand | Tier 5 | $0.00 | Details |
| 16 | Potassium Chloride | Brand | Tier 2 | $0.00 | Details |
| 17 | Bromocriptine mesylate | Brand | Tier 4 | $0.00 | Details |
| 18 | Dicyclomine Dicyclomine hydrochloride | Brand | Tier 3 | $0.00 | Details |
| 19 | Fluphenazine Hydrochloride | Brand | Tier 4 | $0.00 | Details |
| 20 | Verzenio abemaciclib | Brand | Tier 5 | $0.00 | Details |
Showing 20 of 995 covered drugs.
States Served (1)
This plan is available to Medicare beneficiaries in the following states.
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