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DEVOTED CORE 005 HI (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CORE 005 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 005 HI (HMO) in 2026, please refer to our full plan details page.
DEVOTED CORE 005 HI (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Kauai and Maui Counties. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CORE 005 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 005 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 005 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 005 HI (HMO) Medicare plan features an annual prescription drug deductible of $475. Under this plan, you will pay no copay for Tier 1 preferred generic and Tier 2 generic medications when using standard pharmacies or standard mail order services. This zero-dollar cost sharing applies to one-month, two-month, and three-month supplies of these generic drugs. For brand-name and specialty medications, your costs are based on a percentage of the drug cost rather than flat copays. You will pay a 22% coinsurance for Tier 3 preferred brand drugs and a 25% coinsurance for Tier 4 non-preferred drugs through standard retail or mail order channels. Tier 5 specialty tier drugs require a 27% coinsurance for a one-month supply.
Additional Benefits
The Devoted Core 005 HI (HMO) plan offers affordable healthcare coverage with no copay or coinsurance for primary care visits, while specialist visits require a $40 copay. For hospital stays, inpatient services have a $370 daily copay for the first five days and no copay for days 6 through 90, while home health services and select outpatient procedures are available with no copay. Emergency care is covered with a $130 copay, which is waived if you are admitted, and urgent care visits range from no copay up to a $45 copay. This plan also includes valuable supplemental benefits, such as dental coverage up to a $3,000 annual limit with no copay for preventive services and 0% to 50% coinsurance for comprehensive care. Vision care features a $350 annual allowance for eyewear with no copay, while routine hearing exams require a $40 copay and prescription hearing aids range from a $399 to $699 copay. Additionally, members benefit from a quarterly $50 over-the-counter allowance and no copay for fitness benefits and annual physical exams.
Inpatient Hospital See details
Inpatient hospital services are covered by DEVOTED CORE 005 HI (HMO) with no coinsurance, requiring a $370 daily copayment for days 1 through 5 and no copay for days 6 through 90 per stay. This partially covered benefit includes unlimited additional days for acute care, but excludes coverage for upgrades, non-Medicare-covered stays, and additional psychiatric days.
Outpatient Services See details
DEVOTED CORE 005 HI (HMO) outpatient services are covered with no coinsurance, featuring no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $470, observation services require a $370 copay per stay, and outpatient substance abuse sessions have a $40 copay.
Partial Hospitalization See details
DEVOTED CORE 005 HI (HMO) covers partial hospitalization services with a $70.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by DEVOTED CORE 005 HI (HMO), as transportation services to plan-approved or general health-related locations are not covered. Prior authorization is required for all ambulance services, with ground ambulance requiring a copay ranging from no copay to $275 plus coinsurance, and air ambulance requiring a 20% coinsurance plus a copay.
Emergency Services See details
DEVOTED CORE 005 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 range from no copay to a $45 copay with no coinsurance, and worldwide emergency services are covered up to a $25,000 lifetime limit with a $130 copay for emergency or urgent care and a $275 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
Primary care benefits under DEVOTED CORE 005 HI (HMO) feature no copay and no coinsurance for primary care physician visits, while specialist visits require a $40 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance for routine care (other chiropractic services are not covered), whereas podiatry services are not covered.
Preventive Services See details
DEVOTED CORE 005 HI (HMO) provides preventive services, including annual physical exams and kidney disease education, with no copay and no coinsurance. Additional preventive benefits are partially covered with no copay—including fitness benefits, alternative therapies (0% to 50% coinsurance), and therapeutic massage (50% coinsurance)—while services like personal emergency response systems, in-home safety assessments, medical nutrition therapy, and counseling are not covered.
Hearing Services See details
Hearing services are covered by DEVOTED CORE 005 HI (HMO) with no coinsurance, requiring a $40 copay for annual routine exams and a $399 to $699 copay for up to two annual prescription hearing aids. The benefit is partially covered, as over-the-counter (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 under DEVOTED CORE 005 HI (HMO) are partially covered, offering routine eye exams with a $0 to $40 copay and no coinsurance, while other eye exam services are not covered. Covered eyewear, including contacts, eyeglasses, and upgrades, has no copay and no coinsurance up to a $350 annual maximum benefit.
Dental Services See details
Dental services are partially covered by DEVOTED CORE 005 HI (HMO) with a $3,000 annual maximum, offering preventive and select comprehensive services with no copay and no coinsurance, while other comprehensive services have no copay and 0% to 50% coinsurance. Medicare-covered dental services require a $40 copay and no coinsurance, but maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by DEVOTED CORE 005 HI (HMO) with no copay, although prior authorization is required. Covered Medicare Part B drugs, such as chemotherapy, radiation, and insulin, require a coinsurance between 0% and 20%, with insulin drugs carrying a $35 copay.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CORE 005 HI (HMO) plan with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED CORE 005 HI (HMO) with no copays for covered items, though prior authorization is required and coinsurance ranges from no coinsurance up to 20%. Durable medical equipment carries a 20% coinsurance, and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CORE 005 HI (HMO) covers diagnostic and radiological services with prior authorization required. Diagnostic services feature no coinsurance, offering lab services with no copay and diagnostic tests with a $0 to $95 copay, while radiological services range from no copay for outpatient X-rays to a 20% minimum coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered by the DEVOTED CORE 005 HI (HMO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CORE 005 HI (HMO) does not cover Cardiac Rehabilitation Services, as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all not covered by the plan.
Skilled Nursing Facility (SNF) See details
DEVOTED CORE 005 HI (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no prior three-day hospital stay but requiring prior authorization. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the standard Medicare benefit are not covered.
Other Services See details
DEVOTED CORE 005 HI (HMO) provides coverage for acupuncture with no copay and 50% coinsurance, alongside additional preventive services and over-the-counter (OTC) items with no copay and no coinsurance. OTC benefits include up to $50 every three months, though meal benefits are not covered.
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