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DEVOTED C-SNP PREMIUM 016 PA (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 PA (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 PA (HMO C-SNP) in 2026, please refer to our full plan details page.
DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) is a HMO C-SNP plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Philadelphia Area. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED C-SNP PREMIUM 016 PA (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 PA (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 PA (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 PA (HMO C-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $32.70. 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 $7800.00 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 PA (HMO C-SNP) plan features an annual prescription drug deductible of $615. Under this plan, Tier 6 Select Care Drugs are covered with no copay for one-month, two-month, and three-month supplies through standard retail pharmacies and standard mail order. For other generic medications, standard pharmacy and mail-order fills cost an $18 copay for a one-month supply of Tier 1 Preferred Generics and a $20 copay for Tier 2 Generics. For higher-tier medications, costs are determined by coinsurance rather than flat copayments. Tier 3 Preferred Brands carry a 23% coinsurance, while Tier 4 Non-Preferred Drugs require a 26% coinsurance. Additionally, Tier 5 Specialty Tier drugs require a 25% coinsurance for a one-month supply through standard pharmacies or standard mail order.
Additional Benefits
The DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) plan offers robust medical coverage with no copay for primary care visits, telehealth services, and preventive care. For hospital stays, members pay a daily copay of $375 for the first several days of inpatient care, while outpatient services range from no copay to a $475 copay. Emergency room visits require a $115 copay, which is waived if you are admitted, and urgent care ranges from no copay to $40. Specialist visits require a $35 to $50 copay, while home health services are available with no copay. The plan also features strong ancillary benefits, including up to $2,000 annually for select dental services with no copay, a $300 annual eyewear allowance, and a $50 quarterly over-the-counter item allowance. Hearing exams are covered with a $35 copay, and prescription hearing aids require a copay of $399 to $699.
Inpatient Hospital See details
DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) covers inpatient hospital services with no coinsurance, requiring a $375 daily copay for days 1 through 7 of acute stays (no copay for days 8 through 90) and days 1 through 5 of psychiatric stays (no copay for days 6 through 90). Prior authorization is required for these services, while upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) with no coinsurance, though prior authorization is required for most care. Covered benefits include outpatient hospital services with a $0 to $475 copay, observation services at a $375 copay per stay, outpatient substance abuse sessions for a $35 copay, and both ambulatory surgical center and blood services with no copay.
Partial Hospitalization See details
DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) covers partial hospitalization services with a $60.00 copay and no coinsurance. Prior authorization is required to receive coverage for this benefit.
Ambulance and Transportation Services See details
DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) covers ground ambulance services with a copay ranging from no copay to $315 plus coinsurance, and air ambulance services with a 20% coinsurance plus a copay, both requiring prior authorization. While some transportation services are covered, transportation to plan-approved health-related locations and any other health-related locations is not covered.
Emergency Services See details
Emergency services are covered by DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no copay to a $40 copay with no coinsurance, while worldwide emergency services are covered up to a $25,000 lifetime maximum with copays of $115 to $315 and 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) offers primary care physician services and select telehealth benefits with no copay and no coinsurance. Specialist visits, mental health, podiatry, and physical therapy services require copays ranging from $35 to $50 and no coinsurance, though routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) with no copay and no coinsurance for covered benefits like annual physical exams, fitness benefits, and kidney disease education. Excluded from coverage are several sub-services, including in-home safety assessments, personal emergency response systems (PERS), therapeutic massage, and in-home support services.
Hearing Services See details
Hearing services are partially covered by DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP), featuring a $35 copay and no coinsurance for hearing exams, and a copay ranging from $399 to $699 with no coinsurance for prescription hearing aids. OTC hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) vision services are partially covered, featuring one routine eye exam per year with a $0 to $35 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, providing up to a $300 annual benefit for contacts, eyeglasses, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP), which offers Medicare-covered dental with a $35 copay and no coinsurance, alongside other covered dental services up to a $2,000 annual limit with no copay and no coinsurance. However, implant services, orthodontics, maxillofacial prosthetics, other diagnostic dental services, and other preventive dental services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy, insulin, and other drugs, have a coinsurance ranging from no coinsurance to 20%, with insulin also requiring a $35 copay.
Dialysis Services See details
DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive this covered benefit.
Medical Equipment See details
DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) covers medical equipment with no copay, though prior authorization is required. Durable medical equipment requires a 20% coinsurance, prosthetics and medical supplies carry no coinsurance to 20% coinsurance, and diabetic equipment is partially covered as diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) covers diagnostic and radiological services, requiring prior authorization for all services. Lab services and outpatient X-rays have no copays, diagnostic tests range from a $0 to $95 copay with no coinsurance, and therapeutic radiology services require a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered by DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) with no coinsurance and require prior authorization. While some services are covered, key sub-services such as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered under this plan.
Skilled Nursing Facility (SNF) See details
DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) covers Skilled Nursing Facility (SNF) services 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 the Medicare-covered 100 days are not covered.
Other Services See details
DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) partially covers other services, providing no copay and no coinsurance for over-the-counter (OTC) items up to $50 every three months, non-Medicare covered diabetic shoes, and additional preventive services. Acupuncture, meal benefits, and dual-eligible SNP services are not covered under this plan.
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