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DEVOTED PREMIUM 002 OH (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED PREMIUM 002 OH (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED PREMIUM 002 OH (HMO) in 2026, please refer to our full plan details page.
DEVOTED PREMIUM 002 OH (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Northern Ohio. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that DEVOTED PREMIUM 002 OH (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about DEVOTED PREMIUM 002 OH (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For DEVOTED PREMIUM 002 OH (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $31.40. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $615.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4500.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The DEVOTED PREMIUM 002 OH (HMO) plan features an annual drug deductible of $615. Under this plan, Tier 1 preferred generic drugs have no copay for one-month, two-month, and three-month supplies at standard pharmacies and standard mail order. Tier 2 generic drugs have a low copay starting at $3.00 for a one-month supply. Brand-name and specialty prescriptions are covered via coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 23% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance. These cost-sharing percentages apply to both standard pharmacy and standard mail order options.
Additional Benefits
The DEVOTED PREMIUM 002 OH (HMO) plan offers comprehensive medical coverage featuring no copay or coinsurance for primary care doctor visits and annual preventive services. For inpatient hospital stays, members pay a $300 daily copay for the first six days and no copay for days 7 through 90, while outpatient hospital visits range from no copay up to a $400 copay. Emergency services are covered with a $130 copay, which is waived if you are admitted to the hospital within 24 hours. This plan also includes valuable supplemental benefits, such as up to $3,000 in annual dental coverage with no copay for preventive care and 0% to 50% coinsurance for restorative services. Vision benefits provide up to a $300 annual allowance for eyewear with no copay, and hearing aids are covered with copays ranging from $199 to $499. Additionally, members can access up to $100 in over-the-counter items every three months with no copay and no coinsurance.
Inpatient Hospital See details
DEVOTED PREMIUM 002 OH (HMO) covers inpatient hospital services with no coinsurance, requiring a $300 daily copay for days 1 through 6 and no copay for days 7 through 90. Unlimited additional days are covered for acute hospital stays, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED PREMIUM 002 OH (HMO) with no coinsurance for all services, requiring a $0 to $400 copay for outpatient hospital visits and a $300 copay per stay for observation services. Ambulatory surgical center and blood services have no copay, while outpatient substance abuse sessions carry a $40 copay.
Partial Hospitalization See details
Partial hospitalization services are covered by DEVOTED PREMIUM 002 OH (HMO) with a $55.00 copay and no coinsurance. Prior authorization is required to receive this benefit.
Ambulance and Transportation Services See details
DEVOTED PREMIUM 002 OH (HMO) covers ground ambulance services with a copay ranging from no copay to $315.00 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, both requiring prior authorization. Transportation services are not covered under this plan.
Emergency Services See details
Emergency services under DEVOTED PREMIUM 002 OH (HMO) are covered with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no coinsurance and range from no copay to a $45 copay, while worldwide emergency services are covered up to $25,000 with a $130 copay and no coinsurance for emergency or urgent care, and a $315 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED PREMIUM 002 OH (HMO) covers primary care physician services with no copay and no coinsurance, and specialist, therapy, and mental health services with copays ranging from $40 to $50 and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance, though routine chiropractic care and other chiropractic services are not covered, while podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered under the DEVOTED PREMIUM 002 OH (HMO) plan with no copay and no coinsurance for covered options like annual physicals, fitness benefits, and kidney disease education. Uncovered sub-services include in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, therapeutic massage, adult day health, palliative care, in-home support, caregiver support, additional smoking cessation, disease management, telemonitoring, remote access, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED PREMIUM 002 OH (HMO), featuring a $40 copay and no coinsurance for one routine hearing exam per year, and no copay or coinsurance for unlimited fitting evaluations. Prescription hearing aids are covered for up to two devices per year with a copay between $199 and $499 and no coinsurance, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED PREMIUM 002 OH (HMO), which offers one routine eye exam per year with a $0 to $40 copay, no coinsurance, and prior authorization required, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $300 annual limit for contacts, eyeglasses, lenses, frames, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED PREMIUM 002 OH (HMO) up to a $3,000 annual maximum, offering no copay and no coinsurance for preventive care, and no copay with 0% to 50% coinsurance for restorative services. Medicare-covered dental services require a $40 copay and no coinsurance, while orthodontics, implant services, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED PREMIUM 002 OH (HMO) with no copay, though prior authorization is required. Covered Medicare Part B drugs, including chemotherapy and insulin, have a coinsurance ranging from no coinsurance to 20%, with insulin also requiring a $35 copay.
Dialysis Services See details
DEVOTED PREMIUM 002 OH (HMO) covers Dialysis Services with no copay and a 20% coinsurance, although prior authorization is required for these services.
Medical Equipment See details
Medical equipment is covered by DEVOTED PREMIUM 002 OH (HMO) with no copays, though prior authorization is required. Durable medical equipment carries 20% to 50% coinsurance, prosthetics and medical supplies require no coinsurance to 20% coinsurance, and diabetic equipment is partially covered with no coinsurance to 50% coinsurance for supplies, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED PREMIUM 002 OH (HMO) covers diagnostic and radiological services with prior authorization required. Diagnostic services have no coinsurance, featuring no copay for lab services and a $0 to $100 copay for procedures, while radiological services feature no copay for X-rays, a $0 minimum copay for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Home Health Services are covered by DEVOTED PREMIUM 002 OH (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the DEVOTED PREMIUM 002 OH (HMO) plan, as all related rehabilitation services—including intensive cardiac, pulmonary, and supervised exercise therapy—are not covered in practice.
Skilled Nursing Facility (SNF) See details
DEVOTED PREMIUM 002 OH (HMO) covers skilled nursing facility (SNF) services with no coinsurance, requiring prior authorization but allowing admission without a prior three-day hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED PREMIUM 002 OH (HMO) partially covers other services, offering additional preventive services and up to $100 in over-the-counter items every three months with no copay and no coinsurance. Acupuncture, meal benefits, and dual-eligible SNP services are not covered under this benefit.
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