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DEVOTED CORE 014 PA (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CORE 014 PA (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED CORE 014 PA (HMO) in 2026, please refer to our full plan details page.
DEVOTED CORE 014 PA (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Western Pennsylvania Area. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CORE 014 PA (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 014 PA (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 014 PA (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 $375.00 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 $5900.00 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 014 PA (HMO) medicare plan features an annual prescription drug deductible of $375. Under this plan, you will pay no copay for Tier 1 preferred generic and Tier 2 generic drugs when using standard retail pharmacies or standard mail order services. This zero-dollar cost-sharing applies to one-month, two-month, and three-month supplies. For higher-tier prescriptions, cost-sharing transitions to coinsurance percentages at standard pharmacies and standard mail order. Tier 3 preferred brand drugs require a 19% coinsurance, and Tier 4 non-preferred drugs require a 25% coinsurance. Tier 5 specialty medications carry a 28% coinsurance, which is limited to a one-month supply.
Additional Benefits
The DEVOTED CORE 014 PA (HMO) plan offers comprehensive medical coverage featuring no copay for primary care physician visits and a $30 copay for specialist visits. Patients pay a $240 daily copay for the first six days of inpatient acute hospital stays, after which there is no copay, while emergency room visits require a $130 copay that is waived if admitted. Outpatient services feature no coinsurance, with copays ranging from no copay to $340 depending on the specific service. This plan also includes valuable everyday health benefits, such as dental coverage up to a $4,000 annual limit with many services requiring no copay. Additionally, members benefit from a $350 annual allowance for eyewear, no copay for routine annual physicals, and a $100 over-the-counter allowance every three months. Routine hearing exams are available for a $30 copay, alongside coverage for prescription hearing aids.
Inpatient Hospital See details
Inpatient hospital services are covered by DEVOTED CORE 014 PA (HMO) with no coinsurance, requiring prior authorization and a $240 daily copay for days 1 through 6 for acute care (no copay for days 7 and beyond) or a $240 daily copay for days 1 through 5 for psychiatric care (no copay for days 6 through 90). This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED CORE 014 PA (HMO) with no coinsurance, featuring a $0 to $340 copay for outpatient hospital services and a $240 copay per stay for observation services. Ambulatory surgical center and outpatient blood services are available with no copay and no coinsurance, while outpatient substance abuse sessions require a $30 copay and no coinsurance.
Partial Hospitalization See details
DEVOTED CORE 014 PA (HMO) covers partial hospitalization services with a $60.00 copay and no coinsurance. Prior authorization is required for this covered benefit.
Ambulance and Transportation Services See details
Ambulance services under DEVOTED CORE 014 PA (HMO) require prior authorization, offering ground transport with a copay of $0 to $315 and air transport with a 20% coinsurance. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
DEVOTED CORE 014 PA (HMO) covers emergency services with a $130 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services with no copay to a $45 copay and no coinsurance. Worldwide emergency and urgent services are covered up to a $25,000 maximum with a $130 copay and no coinsurance, while worldwide emergency transportation requires a $315 copay and 20% coinsurance.
Primary Care See details
DEVOTED CORE 014 PA (HMO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $30 copay and no coinsurance. Physical, occupational, and speech therapies require a $30 to $50 copay and no coinsurance, while podiatry and chiropractic services are not covered. Mental health, psychiatric, and telehealth services are available with copays ranging from $0 to $45 and no coinsurance.
Preventive Services See details
Preventive Services are partially covered by DEVOTED CORE 014 PA (HMO) with no copay and no coinsurance for covered options like annual physicals, kidney disease education, and fitness benefits. Uncovered sub-services include in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, tobacco cessation counseling, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED CORE 014 PA (HMO), featuring routine hearing exams for a $30 copay and no coinsurance, and prescription hearing aids for a $399 to $699 copay and no coinsurance. OTC hearing aids, along with inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
DEVOTED CORE 014 PA (HMO) provides partially covered vision services, featuring one routine eye exam per year with a $0 to $30 copay, no coinsurance, and no deductible, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible up to a combined maximum plan benefit of $350 per year for contacts, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED CORE 014 PA (HMO) up to a $4,000 annual maximum, though maxillofacial prosthetics, implant services, and orthodontics are not covered. Medicare-covered dental services require a $30 copay and no coinsurance, while other covered services feature no copay and coinsurance ranging from no coinsurance to 50%.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED CORE 014 PA (HMO) with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and other drugs, require a coinsurance ranging from no coinsurance to 20%, while Medicare Part B insulin has a $35 copay and a coinsurance of no coinsurance to 20%.
Dialysis Services See details
DEVOTED CORE 014 PA (HMO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
DEVOTED CORE 014 PA (HMO) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment incurs a 20% to 30% coinsurance, while covered prosthetics, medical supplies, and diabetic supplies range from no coinsurance up to 20% or 30% coinsurance. Diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CORE 014 PA (HMO) with prior authorization required for most services. Lab services feature no copay and no coinsurance, diagnostic tests range from a $0 to $95 copay with no coinsurance, and therapeutic radiology requires a minimum 20% coinsurance.
Home Health Services See details
DEVOTED CORE 014 PA (HMO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are provided by the DEVOTED CORE 014 PA (HMO) plan with no coinsurance and require prior authorization. While some services are covered, standard cardiac rehabilitation ($30 copay), intensive cardiac rehabilitation ($30 copay), pulmonary rehabilitation ($30 copay), and supervised exercise therapy for peripheral artery disease ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CORE 014 PA (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $218 copay for days 21 through 100. Prior authorization is required, a prior 3-day hospital stay is not required for admission, and additional days beyond the standard 100 days are not covered.
Other Services See details
DEVOTED CORE 014 PA (HMO) partially covers other services, providing over-the-counter (OTC) items up to $100 every three months and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and dual-eligible SNP services are not covered.
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