A non-government entity
Devoted PREMIUM South Carolina (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted PREMIUM South Carolina (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted PREMIUM South Carolina (HMO) in 2025, please refer to our full plan details page.
Devoted PREMIUM South Carolina (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in South Carolina. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Devoted PREMIUM South Carolina (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 South Carolina (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 South Carolina (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $29.80. 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 $590.00 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 $4900.00 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:
Sign up for Devoted PREMIUM South Carolina (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Devoted PREMIUM South Carolina (HMO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590.00. In the initial coverage phase, after you pay the deductible, you will pay either 25% coinsurance or no copay, depending on the drug tier and pharmacy. In the catastrophic coverage phase, you pay nothing for Part D covered drugs after your yearly out-of-pocket drug costs reach $2000.00.
Additional Benefits
The Devoted PREMIUM South Carolina (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay of $295 for days 1-5, and no copay for days 6-90. Outpatient services include copays from $0 to $395, and emergency services have a $125 copay. This plan covers primary care, preventive, hearing, vision, and dental services. Primary care has a $15 copay for some services, and routine eye exams and hearing exams each have a $15 copay. Dental services have a $15 copay for Medicare dental services and a $500 annual maximum for other services.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization. For days 1-5, there is a $295 copay, and for days 6-90, there is no copay. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $395, Observation Services with a $295 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a $15 copay for both individual and group sessions, and Outpatient Blood Services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted PREMIUM South Carolina (HMO) plan, with a $60 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Devoted PREMIUM South Carolina (HMO). Medicare-covered ground ambulance services have a copay ranging from $0.00 to $275.00, and air ambulance services have a 20% coinsurance; however, transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $125 copay, and Urgently Needed Services have a copay between $0 and $45. Worldwide Emergency Transportation has a 20% coinsurance and a $275 copay, while Worldwide Emergency Coverage and Worldwide Urgent Coverage both have a $125 copay.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Chiropractic Services have a $15 copay for routine care, and both Individual and Group Sessions for Mental Health and Psychiatric Services have a $15 copay. Other Health Care Professional services have a copay that ranges from $0 to $15, Physical Therapy and Speech-Language Pathology Services have a copay between $15 and $50, and Opioid Treatment Program Services have a $15 copay. Routine Chiropractic Care is not covered, and Podiatry Services are not covered.
Preventive Services See details
Preventive Services includes coverage for Medicare-covered preventive services, annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, kidney disease education, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit. The plan does not cover In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Therapeutic Massage, Adult Day Health Services, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), and Counseling Services.
Hearing Services See details
Hearing Services includes routine hearing exams with a $15 copay, and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a copay between $199 and $499, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
The Devoted PREMIUM South Carolina (HMO) plan covers vision services including routine eye exams with a $15 copay, and eyewear with a combined maximum of $500 per year. This plan also covers contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
Devoted PREMIUM South Carolina (HMO) covers dental services including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. The plan has a $15 copay for Medicare Dental Services, and a maximum benefit of $500 per year for other dental services; maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted PREMIUM South Carolina (HMO) plan. The coinsurance for these services is between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance between 0% and 25%, and Prosthetics/Medical Supplies with no copay and coinsurance for Medicare-covered devices and supplies. Durable Medical Equipment for use outside the home and Diabetic Supplies/Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
The Devoted PREMIUM South Carolina (HMO) plan covers Diagnostic and Radiological Services, including Diagnostic Procedures/Tests with a copay between $0 and $95, and Lab Services with no copay. Diagnostic Radiological Services have a copay up to $300, while Therapeutic Radiological Services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Devoted PREMIUM South Carolina (HMO) plan with no copay and no coinsurance, but prior authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Devoted PREMIUM South Carolina (HMO) plan. Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are also not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Devoted PREMIUM South Carolina (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The "Other Services" benefit for Devoted PREMIUM South Carolina (HMO) covers some services, but does not cover acupuncture, over-the-counter items, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing services, case management, institution for mental disease services for individuals 65 or older, services in an intermediate care facility for individuals with intellectual disabilities, case management, tobacco cessation counseling for pregnant women, freestanding birth center services, respiratory care services, family planning services, nursing home services, home and community based services, personal care services, and self-directed personal assistance services. Other 2 benefits are covered, including $0 preventive services.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved