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DEVOTED CORE 004 HI (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CORE 004 HI (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED CORE 004 HI (HMO) in 2026, please refer to our full plan details page.
DEVOTED CORE 004 HI (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Honolulu County. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CORE 004 HI (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 CORE 004 HI (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 CORE 004 HI (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 $475.00 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 $6200.00 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 CORE 004 HI (HMO) Medicare plan has an annual prescription drug deductible of $475. This plan offers savings on common medications, featuring no copay for Tier 1 preferred generic and Tier 2 generic drugs for up to a 3-month supply at standard pharmacies or through standard mail order. For brand-name and specialty prescriptions, costs are calculated using coinsurance at standard pharmacies and standard mail order services. You will pay a 22% coinsurance for Tier 3 preferred brand drugs, a 25% coinsurance for Tier 4 non-preferred drugs, and a 27% coinsurance for a 1-month supply of Tier 5 specialty drugs.
Additional Benefits
The DEVOTED CORE 004 HI (HMO) Medicare plan offers comprehensive medical coverage, including primary care visits with no copay and specialist visits for a $40 copay. Inpatient hospital stays require a $370 daily copay for the first five days and no copay for days 6 through 90, while emergency room visits carry a $130 copay that is waived upon admission. Outpatient services feature no coinsurance, with ambulatory surgical center visits requiring no copay and diagnostic lab and X-ray services also covered at no cost. This plan also provides robust supplemental benefits, featuring preventive dental care with no copay and comprehensive dental services up to a $3,000 annual maximum. Vision benefits include a $350 annual allowance for eyewear with no copay, while hearing aid coverage ranges from a $399 to $699 copay per device. Skilled nursing facility stays are covered with no copay for the first 20 days, and durable medical equipment is available with no copay and a 20% coinsurance.
Inpatient Hospital See details
DEVOTED CORE 004 HI (HMO) covers inpatient acute and psychiatric hospital services with no coinsurance, requiring a $370 copay per day for days 1 through 5 and no copay for days 6 through 90. This benefit is partially covered as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, though unlimited additional acute care days are included.
Outpatient Services See details
Outpatient services under DEVOTED CORE 004 HI (HMO) are covered with no coinsurance, though prior authorization is required for most services. Patients pay no copay for ambulatory surgical center and outpatient blood services, while outpatient hospital visits range from a $0 to $470 copay, observation services carry a $370 copay per stay, and outpatient substance abuse sessions require a $40 copay.
Partial Hospitalization See details
Partial hospitalization services are covered by DEVOTED CORE 004 HI (HMO) with a copay of $70.00 and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by DEVOTED CORE 004 HI (HMO), with ground ambulance services requiring a copay ranging from no copay to $275 and no coinsurance, and air ambulance services requiring a 20% coinsurance and no copay. Prior authorization is required for all ambulance services, and routine transportation services to health-related locations are not covered.
Emergency Services See details
DEVOTED CORE 004 HI (HMO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require no copay to a $45 copay with no coinsurance, and worldwide emergency services are covered up to $25,000 with a $130 copay and no coinsurance for emergency or urgent care, and a $275 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CORE 004 HI (HMO) covers primary care physician visits with no copay and no coinsurance, while specialist and psychiatric services carry a $40 copay and no coinsurance. Physical and occupational therapies require a $40 to $50 copay with no coinsurance, routine chiropractic care is limited to 12 visits at a $15 copay with no coinsurance, and podiatry services are not covered.
Preventive Services See details
DEVOTED CORE 004 HI (HMO) preventive services are partially covered, offering no copay and no coinsurance for most services like annual physicals and kidney disease education, though alternative therapies require a 0% to 50% coinsurance and therapeutic massage carries a 50% coinsurance. Not covered under this benefit are In-Home Safety Assessments, Personal Emergency Response Systems (PERS), Medical Nutrition Therapy (MNT), post-discharge medication reconciliation, re-admission prevention, wigs for chemotherapy hair loss, Adult Day Health Services, Home-Based Palliative Care, In-Home Support Services, caregiver support, additional smoking cessation counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies, and Counseling Services.
Hearing Services See details
Hearing services are partially covered by DEVOTED CORE 004 HI (HMO), excluding OTC hearing aids as well as inner ear, outer ear, and over the ear prescription hearing aids. Routine hearing exams require a $40 copay and no coinsurance, while covered prescription hearing aids cost a $399 to $699 copay with no coinsurance for up to two devices per year.
Vision Services See details
DEVOTED CORE 004 HI (HMO) provides partially covered vision services with no deductibles, which includes one routine eye exam per year with a $0 to $40 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay or coinsurance up to a $350 annual maximum for contacts, eyeglasses, lenses, frames, and upgrades.
Dental Services See details
DEVOTED CORE 004 HI (HMO) dental services are partially covered up to a $3,000 yearly maximum, offering no copay and no coinsurance for preventive care, and no copay with 0% to 50% coinsurance for restorative, endodontic, and prosthodontic services. Medicare-covered dental services require a $40 copay and no coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CORE 004 HI (HMO) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs have no copay and no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under DEVOTED CORE 004 HI (HMO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Medical equipment is covered by DEVOTED CORE 004 HI (HMO) with no copays and prior authorization required, featuring a 20% coinsurance for durable medical equipment and no coinsurance to 20% coinsurance for prosthetics, medical supplies, and diabetic supplies. This benefit is partially covered, as diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CORE 004 HI (HMO) covers diagnostic and radiological services, requiring prior authorization for all services. Lab services, diagnostic radiology, and outpatient X-rays have no copay, diagnostic tests have a copay of $0 to $95 with no coinsurance, and therapeutic radiology has a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED CORE 004 HI (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered under DEVOTED CORE 004 HI (HMO) with no coinsurance and require prior authorization. Some services are covered, but cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CORE 004 HI (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, with no coverage provided for additional days.
Other Services See details
Other services are partially covered by DEVOTED CORE 004 HI (HMO), which offers acupuncture with no copay and 50% coinsurance, as well as over-the-counter items and additional preventive services with no copay and no coinsurance. Meal benefits are not covered under this plan.
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