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DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) in 2026, please refer to our full plan details page.
DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) is a HMO C-SNP plan offered by Devoted Health, Inc. available for enrollment in 2026 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 C-SNP PREMIUM 017 OH (HMO C-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP).
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 C-SNP PREMIUM 017 OH (HMO C-SNP), 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 $4600.00 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 C-SNP PREMIUM 017 OH (HMO C-SNP) plan features an annual drug deductible of $615. Under this plan, you will pay no copay for Tier 6 select care drugs at standard pharmacies and standard mail-order services. For Tier 1 preferred generic drugs, standard costs start at an $18 copay for a one-month supply, while Tier 2 generic drugs require a $20 copay. Higher tier prescription drugs are subject to coinsurance rather than flat copays during the initial coverage phase. Tier 3 preferred brand drugs require a 23% coinsurance, and Tier 4 non-preferred drugs have a 26% coinsurance. Tier 5 specialty drugs are covered with a 25% coinsurance for a one-month supply at standard pharmacies and mail-order.
Additional Benefits
The DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) plan offers comprehensive coverage featuring no copays or coinsurance for primary care visits, preventive services, and home health care. For specialized medical needs, members pay predictable copays, such as $40 to $50 for specialist visits, a $130 copay for emergency services, and daily copays for inpatient hospital stays. Outpatient services generally carry no coinsurance, with copays ranging from no copay for ambulatory surgery to $495 for hospital services. This plan also includes valuable supplemental benefits, featuring no copay for preventive and comprehensive dental care up to a $2,000 annual limit, alongside a $300 eyewear allowance. Routine hearing exams require a $40 copay, with covered prescription hearing aids carrying copays between $399 and $699. Additionally, members benefit from a $50 quarterly over-the-counter allowance and no copays for diagnostic lab tests, though durable medical equipment and dialysis require coinsurance.
Inpatient Hospital See details
Inpatient hospital services are covered by DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) with no coinsurance, though the benefit is partially covered as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered. For covered acute stays, there is a $395 daily copay for days 1 through 6 and no copay for days 7 through 90, while psychiatric stays require a $395 daily copay for days 1 through 5 and no copay for days 6 through 90.
Outpatient Services See details
DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) covers outpatient services with no coinsurance, including no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services have a copay of $0 to $495, observation services require a $395 copay per stay, and individual or group outpatient substance abuse sessions have a $40 copay.
Partial Hospitalization See details
Partial hospitalization services are covered under the DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) plan with a $55.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) covers ground ambulance services with a copay of $0 to $315 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required. Transportation services to health-related locations are not covered.
Emergency Services See details
DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) covers emergency services with a $130 copay and no coinsurance (waived if admitted within 24 hours), and urgently needed services with no copay to a $45 copay and no coinsurance. Worldwide emergency and urgent care are covered up to a $25,000 maximum benefit with a $130 copay and no coinsurance, while worldwide emergency transportation requires a $315 copay and 20% coinsurance.
Primary Care See details
DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) covers primary care physician visits with no copay and no coinsurance, while specialist, mental health, and physical therapy services require copays ranging from $40 to $50 and no coinsurance. Chiropractic services are partially covered under this plan, as routine chiropractic care and other chiropractic services are not covered.
Preventive Services See details
Preventive Services are covered by DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) with no copay and no coinsurance, including annual physicals, fitness benefits, and nutritional therapy. The benefit is partially covered, as services such as in-home safety assessments, personal emergency response systems (PERS), therapeutic massage, and in-home support are not covered.
Hearing Services See details
DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) partially covers hearing services, offering one routine hearing exam per year with a $40 copay, no coinsurance, and no deductible, alongside unlimited fitting evaluations. Up to two prescription hearing aids are covered annually with a copay ranging from $399.00 to $699.00 and no coinsurance, though OTC hearing aids and inner ear, outer ear, or over-the-ear prescription models are not covered.
Vision Services See details
DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) partially covers vision services, offering one routine eye exam per year with a $0 to $40 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay or coinsurance up to a $300 annual maximum for contacts, lenses, frames, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP), featuring a $40 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for other covered preventive and comprehensive dental up to a $2,000 yearly maximum. Sub-services that are not covered include other diagnostic and preventive services, maxillofacial prosthetics, implant services, and orthodontics.
Home Infusion bundled Services See details
DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) covers home infusion bundled services with no copay, though prior authorization is required. Covered Medicare Part B insulin drugs require a $35 copay and 0% to 20% coinsurance, while chemotherapy and other Part B drugs have a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) partially covers medical equipment with no copays, although prior authorization is required. Durable medical equipment carries a 20% to 50% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance up to 20% or 50% coinsurance, with diabetic therapeutic shoes and inserts not covered.
Diagnostic and Radiological Services See details
DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) covers diagnostic and radiological services with prior authorization required. Lab services have no copay and no coinsurance, diagnostic tests require a $0 to $95 copay with no coinsurance, and radiological services range from no copay for X-rays to a minimum 20% coinsurance for therapeutic services.
Home Health Services See details
Home Health Services are covered under the DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) plan with no copay and no coinsurance. Prior authorization is required to receive these services.
Cardiac Rehabilitation Services See details
DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) covers Cardiac Rehabilitation Services with no coinsurance and prior authorization required, meaning some services are covered. However, cardiac rehabilitation ($40 copay), intensive cardiac rehabilitation ($40 copay), pulmonary rehabilitation ($35 copay), and supervised exercise therapy for peripheral artery disease ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and additional days beyond the standard 100 days are not covered.
Other Services See details
Other Services under the DEVOTED C-SNP PREMIUM 017 OH (HMO C-SNP) plan are partially covered, featuring no copay and no coinsurance for all covered benefits. Covered services include non-Medicare covered diabetic shoes, additional preventive services, and up to $50 every three months for over-the-counter items, while acupuncture and meal benefits are not covered.
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