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DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED C-SNP PREMIUM 016 NC (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 016 NC (HMO C-SNP) in 2026, please refer to our full plan details page.
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) is a HMO C-SNP plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Charlotte. This plan received an overall rating of 5 out of 5 stars in 2026.
It's important to know that DEVOTED C-SNP PREMIUM 016 NC (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 016 NC (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 016 NC (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 016 NC (HMO C-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $36.20. 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 $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:
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Drug Coverage
The DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) prescription drug plan features an annual drug deductible of $615. For standard pharmacy and standard mail order services, you will pay no copay for Tier 6 Select Care Drugs. Tier 1 Preferred Generic drugs cost an $18 copay for a one-month supply, while Tier 2 Generic drugs require a $20 copay. For higher-tier medications, Tier 3 Preferred Brand drugs carry a 23% coinsurance and Tier 4 Non-Preferred drugs carry a 26% coinsurance. Tier 5 Specialty Tier drugs require a 25% coinsurance for a one-month supply through standard pharmacies and mail order. These details provide a clear picture of your potential out-of-pocket costs under this plan.
Additional Benefits
The DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) plan offers affordable healthcare coverage featuring no copay for primary care physician visits and covered preventive services, while specialist visits require a $30 copay. For hospital stays, inpatient acute care requires a $405 copay for days 1 through 6, followed by no copay for days 7 through 90. Emergency room visits carry a $130 copay which is waived if you are admitted within 24 hours, and outpatient hospital services range from no copay up to a $505 copay. Ancillary benefits include routine vision exams with a copay up to $30, a $300 annual eyewear allowance with no copay, and dental coverage up to $2,000 annually with no copay for select services. Home health services are available with no copay, and skilled nursing facility stays feature no copay for the first 20 days. Essential medical equipment and prosthetics are covered with no copays, requiring only a coinsurance ranging from 20% to 50%.
Inpatient Hospital See details
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) covers inpatient hospital services with no coinsurance, requiring a $405 copay for days 1 through 6 of acute stays (no copay for days 7 through 90) and a $405 copay for days 1 through 5 of psychiatric stays (no copay for days 6 through 90). Prior authorization is required for these services, and while unlimited additional acute days are covered, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Covered outpatient hospital services have copays ranging from $0 to $505, observation services cost a $405 copay per stay, and substance abuse sessions have a $30 copay, with prior authorization required for most services.
Partial Hospitalization See details
Partial hospitalization is covered by DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) with a $60.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance services under the DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) plan require prior authorization, offering ground ambulance services with a $0 to $325 copay and air ambulance services with a 20% coinsurance and no copay. Transportation services are not covered under this plan.
Emergency Services See details
Emergency services are covered by DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) with a $130 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours. Urgently needed services range from no copay to a $45 copay with no coinsurance, while worldwide emergency services are covered up to $25,000 with copays up to $325 and up to 20% coinsurance.
Primary Care See details
Primary care benefits under the DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) plan feature no copay and no coinsurance for primary care physician visits, while specialist visits require a $30 copay and no coinsurance. Other services like therapy, telehealth, and mental health care have copays ranging from $0 to $50 with no coinsurance, though chiropractic services are only partially covered with routine care excluded.
Preventive Services See details
Preventive services are partially covered by DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) with no copay and no coinsurance for covered benefits like annual physicals, kidney disease education, and fitness programs. However, several services are not covered, including personal emergency response systems, therapeutic massages, in-home safety assessments, and caregiver support.
Hearing Services See details
Hearing services are covered by DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP), featuring a $30 copay and no coinsurance for one annual routine hearing exam and unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and copays between $399 and $699 for up to two devices per year, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) partially covers vision services, as other eye exam services are not covered. Routine eye exams are covered with a $0 to $30 copay and no coinsurance, while eyewear is covered with no copay, no coinsurance, and up to a $300 annual maximum benefit.
Dental Services See details
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) covers Medicare-covered dental services with a $30 copay and no coinsurance, and other dental services with no copay and no coinsurance up to a $2,000 yearly maximum. This benefit is partially covered, as implants, orthodontics, maxillofacial prosthetics, and other diagnostic or preventive dental services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) with no copay, though prior authorization and step therapy are required. Covered Part B chemotherapy, radiation, and other infusion drugs have no copay and a coinsurance ranging from no coinsurance to 20%, while Part B insulin has a $35 copay and up to 20% coinsurance.
Dialysis Services See details
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) covers medical equipment with no copays, though diabetic equipment is only partially covered because diabetic therapeutic shoes and inserts are not covered. Covered durable medical equipment requires a 20% to 50% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance up to 20% or 50% coinsurance depending on the item.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) with prior authorization required. Diagnostic services feature no coinsurance, with no copay for lab tests and a $0 to $95 copay for procedures, while radiological services range from no copay for X-rays to a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) with no copay and no coinsurance, although only some services are covered in practice. Standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered, and prior authorization is required for any covered services.
Skilled Nursing Facility (SNF) See details
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, and while a three-day prior hospital stay is not necessary, additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by the DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) plan, featuring over-the-counter items up to $50 every three months, non-Medicare covered diabetic shoes, and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and dual-eligible SNP services are not covered under this benefit.
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