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DEVOTED C-SNP PLUS 003 HI (HMO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED C-SNP PLUS 003 HI (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 PLUS 003 HI (HMO C-SNP) in 2026, please refer to our full plan details page.
DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) is a HMO C-SNP plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Honolulu, Maui and Kauai Counties. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED C-SNP PLUS 003 HI (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 PLUS 003 HI (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 PLUS 003 HI (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 PLUS 003 HI (HMO C-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $42.40. 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 $9250.00 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 PLUS 003 HI (HMO C-SNP) plan features an annual prescription drug deductible of $615. Under this plan, Tier 6 select care drugs are fully covered with no copay for one, two, or three-month supplies at standard pharmacies and through standard mail order. For other lower-tier drugs, you will pay an $18 copay for Tier 1 preferred generics and a $19 copay for Tier 2 generics for a standard one-month supply. Brand-name and specialty drugs are subject to coinsurance rather than flat copayments. Tier 3 preferred brands and Tier 5 specialty drugs both require a 25% coinsurance, while Tier 4 non-preferred drugs carry a 31% coinsurance. These cost-sharing percentages apply to standard pharmacy fills as well as standard mail-order services.
Additional Benefits
The DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) plan offers comprehensive medical coverage featuring no copay and no coinsurance for primary care visits, preventive annual physicals, and home health services. For specialized medical care, members will pay no copay alongside coinsurance rates such as 30% for specialist visits and up to 35% for outpatient hospital and diagnostic services. Inpatient hospital stays require a flat copayment of $2230 for acute care and $2080 for psychiatric care, with no additional coinsurance. For supplemental care, the plan provides a robust dental benefit up to a $4,000 annual limit with no copay and 0% to 50% coinsurance, as well as a $300 annual allowance for eyewear with no copay or coinsurance. Routine hearing exams feature no copay and 35% coinsurance, while prescription hearing aids require a copay ranging from $399 to $699. Additional perks include a $50 quarterly over-the-counter allowance with no copay and acupuncture services with no copay and 50% coinsurance.
Inpatient Hospital See details
Inpatient hospital services are covered by DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) with no coinsurance, requiring a $2230 copayment per stay for acute care and a $2080 copayment per stay for psychiatric care. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, and prior authorization is required.
Outpatient Services See details
DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) covers outpatient services with no copayments, though coinsurance ranges from no coinsurance to 35% for outpatient hospital and ambulatory surgical center services. Outpatient substance abuse and blood services are covered with no copay and a 30% coinsurance, with prior authorization required for most of these services.
Partial Hospitalization See details
DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) covers partial hospitalization services with no copay and a 20% coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance services are covered by DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) with no copay, requiring prior authorization and a coinsurance of 0% to 35% for ground transport and 35% for air transport. Transportation services to plan-approved or health-related locations are not covered.
Emergency Services See details
DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services are covered with no copay and a 0% to 20% coinsurance up to $40, while worldwide emergency, urgent, and transportation services are covered up to $25,000 with no copay and no coinsurance.
Primary Care See details
Primary care benefits under DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) offer primary care physician services with no copay and no coinsurance. Specialist visits, mental health, and therapy services have no copay and 30% coinsurance, while chiropractic services are not covered in practice.
Preventive Services See details
Preventive Services are partially covered by DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) with no copay and no coinsurance for annual physicals and kidney education, though alternative therapies and therapeutic massages require no copay and up to 50% coinsurance. Sub-services that are not covered under this plan include in-home safety assessments, personal emergency response systems (PERS), post-discharge medication reconciliation, readmission prevention, chemotherapy wigs, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED C-SNP PLUS 003 HI (HMO C-SNP), featuring routine hearing exams with no copay and a 35% coinsurance, and up to two prescription hearing aids per year with no coinsurance and a $399 to $699 copay. OTC hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED C-SNP PLUS 003 HI (HMO C-SNP), offering one routine eye exam per year with no copay and 0% to 35% coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance, providing up to a $300 annual maximum for contacts, eyeglasses, and upgrades.
Dental Services See details
DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) dental services are partially covered up to a $4,000 annual limit, offering no copay and no coinsurance for preventive care, and no copay with 0% to 50% coinsurance for restorative services. Medicare-covered dental services have no copay and a 30% coinsurance, but maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) covers Home Infusion bundled Services with no copay and no coinsurance, although prior authorization is required. Associated Medicare Part B drugs—including chemotherapy, radiation, and insulin—are subject to no coinsurance to 20% coinsurance, with insulin also requiring a $35 copay.
Dialysis Services See details
Dialysis services are covered under the DEVOTED C-SNP PLUS 003 HI (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 PLUS 003 HI (HMO C-SNP) covers medical equipment with no copays, though prior authorization is required and coinsurance applies to covered items. Durable medical equipment and diabetic supplies require a 20% coinsurance, while prosthetic devices and medical supplies range from no coinsurance to 20% coinsurance; diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) with prior authorization required and no copays. There is no coinsurance for diagnostic procedures and tests, while a 20% coinsurance applies to therapeutic radiological services, and a 35% coinsurance applies to lab services, diagnostic radiology, and outpatient X-rays.
Home Health Services See details
Home Health Services are covered by DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services under DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) require prior authorization and have no copay, but only some services are covered. Standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) services are not covered and require a 30% coinsurance.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) with no coinsurance, offering no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, a prior 3-day hospital stay is not required, and additional days beyond Medicare-covered limits are not covered.
Other Services See details
DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) partially covers other services, offering acupuncture with no copay and 50% coinsurance, as well as OTC items, diabetic shoes, and additional preventive services with no copay and no coinsurance. Meal benefits are not covered, and OTC items are subject to a maximum benefit of $50 every three months.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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