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DEVOTED C-SNP PLUS 004 VA (HMO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED C-SNP PLUS 004 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 PLUS 004 VA (HMO C-SNP) in 2026, please refer to our full plan details page.
DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) is a HMO C-SNP plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Virginia. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED C-SNP PLUS 004 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 PLUS 004 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 PLUS 004 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 PLUS 004 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 $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 DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) Medicare plan features an annual drug deductible of $615. For prescription coverage through standard pharmacies and standard mail order, Tier 1 preferred generics cost an $18 copay and Tier 2 generics cost a $19 copay for a one-month supply. Additionally, Tier 6 select care drugs are covered with no copay for all supply durations. Higher-tier medications require coinsurance rather than flat copayments under this plan. Tier 3 preferred brands and Tier 5 specialty drugs both carry a 25% coinsurance, with specialty drugs limited to a one-month supply. Tier 4 non-preferred drugs require a 31% coinsurance for standard pharmacy and mail-order fills.
Additional Benefits
The DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) plan offers comprehensive medical coverage, featuring no copays for primary care visits, home health, and preventive services like annual physicals. Outpatient hospital services and specialist visits also feature no copays, though they generally require coinsurance ranging up to 30% or 50%. For emergency care, members pay a $115 copay which is waived if admitted, while inpatient hospital stays require a copay of $2,230 per acute admission with no coinsurance. This plan provides strong supplemental benefits, including dental care with no copay or coinsurance up to a $3,000 annual limit and a $300 yearly allowance for eyewear. Routine hearing exams have no copay and 50% coinsurance, while prescription hearing aids require a copay between $399 and $699. Additionally, skilled nursing facility stays feature no copay for the first 20 days and a daily copay of $218 for days 21 through 100, alongside an over-the-counter item allowance of $50 every three months.
Inpatient Hospital See details
DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) inpatient hospital benefits are partially covered, as upgrades and non-Medicare-covered stays are not covered. Covered acute stays require a $2,230 copay per admission with no coinsurance, while psychiatric stays require a $2,080 copay per admission with no coinsurance, and both require prior authorization.
Outpatient Services See details
DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) covers outpatient services with no copays, though coinsurance and prior authorizations are required for most services. Outpatient hospital and ambulatory surgical center services range from no coinsurance to 50% coinsurance, while outpatient substance abuse and blood services require a 30% coinsurance with no deductible.
Partial Hospitalization See details
DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) covers partial hospitalization services with no copay and a 20% coinsurance. Prior authorization is required before receiving this covered benefit.
Ambulance and Transportation Services See details
DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) covers ambulance services with no copay, requiring no coinsurance to 50% coinsurance for ground ambulance and 50% coinsurance for air ambulance. For transportation, some services are covered but transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Emergency Services for DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) are covered with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require no copay and a 0% to 20% coinsurance up to $40 per visit, while worldwide emergency, urgent, and transportation services are fully covered with no copay and no coinsurance up to a $25,000 maximum limit.
Primary Care See details
DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) offers primary care physician services with no copay and no coinsurance, though chiropractic services are not covered. Most other primary care benefits, such as specialist visits, therapy, and mental health services, are covered with no copay and a 30% coinsurance, while telehealth and other health professionals have a 0% to 30% coinsurance.
Preventive Services See details
Preventive Services are partially covered by DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) with no copay and no coinsurance for covered options like annual physicals, kidney disease education, and fitness programs. Non-covered sub-services include in-home safety assessments, personal emergency response systems (PERS), post-discharge medication reconciliation, readmission prevention, chemo wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, smoking cessation, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) partially covers hearing services, featuring hearing exams with no copay and a 50% coinsurance for routine exams, and prescription hearing aids with no coinsurance and a $399 to $699 copay. Over-the-counter hearing aids, along with inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) partially covers vision services, offering one routine eye exam per year with no copay and 0% to 50% coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $300 annual maximum for contacts, eyeglasses, and upgrades.
Dental Services See details
DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) offers dental services with no copay and no coinsurance up to a $3,000 yearly maximum, while Medicare-covered dental services require a 30% coinsurance and no copay. This benefit is partially covered, as other diagnostic services, other preventive services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) covers Home Infusion bundled Services with no copay, subject to prior authorization. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while insulin requires a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) covers Dialysis Services with no copay and a 20% coinsurance, although prior authorization is required for these services.
Medical Equipment See details
DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) partially covers medical equipment with no copays, requiring prior authorization for covered services. Durable medical equipment and diabetic supplies carry a 20% coinsurance, prosthetics 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
Diagnostic and radiological services are covered under DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) with prior authorization and no copays. Diagnostic procedures and tests have no coinsurance, while therapeutic radiological services require 20% coinsurance, and lab services, diagnostic radiology, and outpatient X-rays carry a 50% coinsurance.
Home Health Services See details
DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) with no copay and no coinsurance, but prior authorization is required. However, some services are not covered, including standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services, which require a 30% coinsurance.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) services are covered by DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) with no coinsurance, featuring no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, and while a prior three-day hospital stay is not needed, additional days beyond the standard 100-day Medicare benefit are not covered.
Other Services See details
Other services are partially covered by DEVOTED C-SNP PLUS 004 VA (HMO C-SNP), offering over-the-counter (OTC) items up to $50 every three months, diabetic shoes, and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and dual-eligible SNP services are not covered under this plan.
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