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DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED C-SNP PREMIUM 003 VA (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 003 VA (HMO C-SNP) in 2026, please refer to our full plan details page.
DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) is a HMO C-SNP plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Western Virginia Highlands. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED C-SNP PREMIUM 003 VA (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 003 VA (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 003 VA (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 003 VA (HMO C-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $24.60. 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 $8200.00 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 003 VA (HMO C-SNP) plan has an annual drug deductible of $615. For Tier 1 preferred generic drugs, you will pay an $18 copay for a one-month supply at standard pharmacies and through standard mail order. Tier 2 generic drugs cost a $20 copay for a one-month supply, while Tier 6 select care drugs are covered with no copay. Higher-tier medications require coinsurance payments at standard pharmacies and standard mail-order services. Tier 3 preferred brand drugs have a 23% coinsurance, while Tier 4 non-preferred drugs carry a 26% coinsurance. Specialty drugs in Tier 5 are covered with a 25% coinsurance for a one-month supply.
Additional Benefits
The DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) plan offers affordable medical coverage, featuring no copay and no coinsurance for primary care visits and covered preventive services. For inpatient hospital stays, there is no coinsurance, though members pay a $405 daily copay for days 1 through 6 of acute stays, with no copay for days 7 through 90. Emergency room visits require a $115 copay, which is waived if you are admitted to the hospital within 24 hours. Specialist visits and Medicare-covered dental services require a $35 copay, with dental benefits covering other services up to a $2,000 annual maximum. Vision and hearing benefits include routine exams with low to no copays, up to $300 for eyewear, and prescription hearing aids starting at a $399 copay. Additionally, members benefit from a $50 quarterly allowance for over-the-counter items with no copay.
Inpatient Hospital See details
DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) covers inpatient hospital services with no coinsurance, requiring a daily copay of $405 for days 1 through 6 of acute stays (no copay for days 7 through 90) and days 1 through 5 of psychiatric stays (no copay for days 6 through 90). This benefit is partially covered because upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) covers outpatient services with no coinsurance, including ambulatory surgical center and blood services with no copay. Outpatient hospital services require a copay ranging from $0 to $505 ($405 per stay for observation services), and outpatient substance abuse sessions carry a $35 copay.
Partial Hospitalization See details
DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) covers partial hospitalization services with an $80.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Ambulance services are covered by DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) with prior authorization, featuring a copay ranging from no copay to $315 (with no coinsurance) for ground transport, and a 20% coinsurance (with no copay) for air transport. Routine transportation services are not covered under this plan.
Emergency Services See details
Emergency services are covered by DEVOTED C-SNP PREMIUM 003 VA (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 require no copay to a $40 copay with no coinsurance, and worldwide emergency services are covered up to $25,000 with copays ranging from $115 to $315 and 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) covers primary care physician services with no copay and no coinsurance, while specialist visits, occupational therapy, psychiatric care, and opioid treatment require a $35 copay and no coinsurance. Physical and speech therapy have a $35 to $50 copay with no coinsurance, telehealth services range from a $0 to $40 copay with no coinsurance, and chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) with no copay and no coinsurance for covered benefits like annual physicals, fitness programs, and kidney disease education. Sub-services that are not covered include in-home safety assessments, personal emergency response systems (PERS), post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, therapeutic massage, adult day health, palliative care, in-home support, caregiver support, additional smoking cessation counseling, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) covers hearing services with a $35 copay and no coinsurance for routine exams, and a $399 to $699 copay with no coinsurance for prescription hearing aids. There is no deductible for these services, but OTC hearing aids and inner, outer, or over-the-ear prescription hearing aid types are not covered.
Vision Services See details
DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) partially covers vision services, offering one routine eye exam per year with no copay to a $35 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no deductible, no copay, and no coinsurance up to a $300 annual maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP), featuring a $35 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other covered services up to a $2,000 annual maximum. Non-covered services include other diagnostic dental, other preventive dental, maxillofacial prosthetics, implant services, and orthodontics.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) with no copay, while associated Medicare Part B chemotherapy, radiation, and other drugs require no coinsurance to 20% coinsurance. Medicare Part B insulin is also covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) plan with no copay and a 20% coinsurance. Prior authorization is required to receive these services.
Medical Equipment See details
DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) covers medical equipment with no copay and prior authorization required, though the benefit is partially covered as diabetic therapeutic shoes and inserts are not covered. Durable medical equipment requires a 20% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) covers diagnostic and radiological services with prior authorization required. Lab services, outpatient X-rays, and diagnostic radiological services have no copay, while diagnostic procedures range from no copay up to $95 with no coinsurance, and therapeutic radiological services require 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) with no coinsurance, though prior authorization is required. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and while a 3-day prior inpatient hospital stay is not required, additional days beyond the standard 100 days are not covered.
Other Services See details
DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) provides partial coverage for other services, offering no copay and no coinsurance for covered benefits like non-Medicare covered diabetic shoes, additional preventive services, and up to $50 every three months for over-the-counter (OTC) items. Acupuncture, meal benefits, and other select services are not covered.
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