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DEVOTED C-SNP PLUS 022 PA (HMO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED C-SNP PLUS 022 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 PLUS 022 PA (HMO C-SNP) in 2026, please refer to our full plan details page.
DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) is a HMO C-SNP plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Pennsylvania. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED C-SNP PLUS 022 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 PLUS 022 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 PLUS 022 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 PLUS 022 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 $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 prescription drug coverage for the DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) plan includes an annual drug deductible of $615. For generic medications, standard pharmacies and mail-order services charge an $18 copay for Tier 1 preferred generics and a $19 copay for Tier 2 generics per month. Additionally, Tier 6 select care drugs are fully covered with no copay for one, two, or three-month supplies. Brand-name and specialty medications under this plan are subject to coinsurance. Tier 3 preferred brands and Tier 5 specialty drugs both require a 25% coinsurance at standard pharmacies. Tier 4 non-preferred drugs carry a 31% coinsurance for standard pharmacy and mail-order fills.
Additional Benefits
The DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) plan offers comprehensive coverage with no copay for primary care visits, preventive care, and home health services. For major medical needs, members will pay a $2,230 copay per stay for acute inpatient hospital care and a $115 copay for emergency room visits, which is waived if admitted. Outpatient services and diagnostic tests generally feature no copays but are subject to coinsurance ranging from 0% to 50%. Vision and dental benefits include routine care with no copay, featuring a $300 annual eyewear allowance and up to a $2,000 annual limit for dental services. Prescription hearing aids require a copay between $399 and $699, while skilled nursing facility stays have no copay for the first 20 days followed by a $218 daily copay. Additionally, the plan provides an over-the-counter allowance of $50 every three months for health-related items.
Inpatient Hospital See details
Inpatient hospital services are covered by DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) with no coinsurance, requiring a $2,230 copay per stay for acute care and a $2,080 copay per stay for psychiatric care. Prior authorization is required for both services, and while unlimited additional days are covered for acute care, upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) covers outpatient services with no copays, though prior authorization is required and coinsurance applies to most benefits. Outpatient hospital and ambulatory surgical center services carry 0% to 50% coinsurance, while outpatient substance abuse and blood services require 30% coinsurance.
Partial Hospitalization See details
DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) covers partial hospitalization services with no copay and a 20% coinsurance. Prior authorization is required to receive this benefit.
Ambulance and Transportation Services See details
Ambulance services are covered by DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) with no copay, requiring prior authorization and either no coinsurance to 50% coinsurance for ground services or 50% coinsurance for air services. Some transportation services are covered, but transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Emergency services are covered under the DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) plan with a $115 copay—which is waived if you are admitted to the hospital within 24 hours—and no coinsurance, while urgently needed services require no copay and a 0% to 20% coinsurance up to $40. Worldwide emergency, urgent, and transportation services are also covered with no copay or coinsurance, up to a maximum lifetime benefit of $25,000.
Primary Care See details
DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) covers primary care physician services with no copay and no coinsurance, and telehealth services with no copay and 0% to 30% coinsurance. Most other specialist, therapy, psychiatric, and substance use services are covered with no copay and 30% coinsurance, although chiropractic services are not covered in practice.
Preventive Services See details
DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) provides partially covered preventive services with no copay and no coinsurance for covered care, including annual physical exams, fitness benefits, and nutritional therapy. However, several supplemental benefits are not covered, such as in-home safety assessments, personal emergency response systems, therapeutic massages, and caregiver support.
Hearing Services See details
DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) hearing services are partially covered, offering hearing exams with no copay and a 50% coinsurance for routine visits, alongside prescription hearing aids 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
DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) partially covers vision services, offering routine eye exams with no copay and 0% to 50% coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, providing a $300 annual maximum allowance for contacts, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED C-SNP PLUS 022 PA (HMO C-SNP), offering no copay and no coinsurance for preventive and comprehensive care up to a $2,000 annual maximum, while Medicare-covered dental services require no copay and a 30% coinsurance. Other diagnostic services, other preventive services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered under DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other Part B drugs carry no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) plan with no copay and a 20% coinsurance. Prior authorization is required for these covered services.
Medical Equipment See details
DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) partially covers medical equipment with no copays, requiring prior authorization for covered services. Durable medical equipment and diabetic supplies have a 20% coinsurance, prosthetic devices and medical supplies range from no coinsurance to 20% coinsurance, and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) covers diagnostic and radiological services with prior authorization and no copayments. Diagnostic procedures and tests require no coinsurance, while therapeutic radiological services have a 20% coinsurance, and lab services, diagnostic radiological services, and outpatient X-rays each carry a 50% coinsurance.
Home Health Services See details
DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered by DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) with no copay and a 30% coinsurance, requiring prior authorization. While some services are covered, Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior 3-day hospital stay required, though prior authorization is necessary. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, but the benefit is only partially covered as additional days beyond the standard Medicare limit are not covered.
Other Services See details
Other services are partially covered by DEVOTED C-SNP PLUS 022 PA (HMO C-SNP), which includes over-the-counter (OTC) items up to $50 every three months, diabetic shoes, and additional preventive services with no copay and no coinsurance. Acupuncture and meal benefits are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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