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DEVOTED CORE 004 CO (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CORE 004 CO (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED CORE 004 CO (HMO) in 2026, please refer to our full plan details page.
DEVOTED CORE 004 CO (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Denver Metro. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that DEVOTED CORE 004 CO (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 004 CO (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 004 CO (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 $370.00 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 $3900.00 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 004 CO (HMO) Medicare plan features an annual drug deductible of $370. Under this plan, you will pay no copay for Tier 1 preferred generic and Tier 2 generic medications at standard pharmacies or through standard mail order. This allows you to fill standard one-month, two-month, and three-month supplies of these common prescriptions at zero cost. For higher-tier drugs, the plan charges coinsurance instead of copays at standard pharmacies and standard mail order. You will pay a 24% coinsurance for Tier 3 preferred brand drugs and a 25% coinsurance for Tier 4 non-preferred drugs. Tier 5 specialty drugs require a 28% coinsurance for a one-month supply.
Additional Benefits
The DEVOTED CORE 004 CO (HMO) plan offers affordable healthcare coverage with no deductible and no copay for primary care doctor visits, while specialist visits require a $25 copay. Inpatient hospital stays feature no coinsurance and a $240 daily copay for the first five days, followed by no copay for days six through 90. Emergency room visits carry a $150 copay, which is waived if you are admitted within 24 hours, while urgent care visits range from no copay up to a $45 copay. This plan also includes valuable dental, vision, and hearing benefits to help lower your out-of-pocket costs. Dental services are covered up to a $3,500 annual maximum with no copay for most preventive and comprehensive services, and routine eye exams and eligible eyewear feature no copay up to a $350 yearly limit. Additionally, members receive a quarterly over-the-counter allowance of $100 with no copay and no coinsurance to purchase health-related items.
Inpatient Hospital See details
DEVOTED CORE 004 CO (HMO) covers inpatient hospital services with no coinsurance, requiring a $240 daily copay for days 1 through 5 and no copay for days 6 through 90 per stay. Unlimited additional days are covered for acute care, but additional psychiatric days, room upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED CORE 004 CO (HMO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services, a $25 copay for outpatient substance abuse sessions, and copays ranging from $0 to $340 for outpatient hospital and observation services. Prior authorization is required for these benefits, which carry no deductibles.
Partial Hospitalization See details
DEVOTED CORE 004 CO (HMO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to receive this benefit.
Ambulance and Transportation Services See details
DEVOTED CORE 004 CO (HMO) covers ambulance services with prior authorization, charging a copay ranging from no copay to $315 plus coinsurance for ground transport, and a 20% coinsurance plus a copay for air transport. These ambulance fees are not waived upon hospital admission, and transportation services are not covered.
Emergency Services See details
DEVOTED CORE 004 CO (HMO) covers emergency services with a $150 copay and no coinsurance, which is waived if admitted within 24 hours, and urgent care with a $0 to $45 copay and no coinsurance. Worldwide emergency services are covered up to a $25,000 limit, featuring a $150 copay and no coinsurance for emergency or urgent care, and a $315 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CORE 004 CO (HMO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $25 copay and no coinsurance. Physical, occupational, speech, and mental health therapies are covered with copays ranging from $25 to $50 and no coinsurance, though podiatry is not covered and chiropractic care is only partially covered.
Preventive Services See details
Preventive services under DEVOTED CORE 004 CO (HMO) are partially covered, offering no copay and no coinsurance for annual physical exams, kidney education, and standard screenings. Supplemental benefits like fitness and nutrition programs feature no copay and no coinsurance, while alternative therapies and therapeutic massages require no copay but carry a coinsurance of up to 50%. However, several sub-services are not covered, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, adult day health, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, remote access, and counseling.
Hearing Services See details
DEVOTED CORE 004 CO (HMO) covers hearing services with a $25 copay and no coinsurance for routine exams, and a $399 to $699 copay with no coinsurance for prescription hearing aids. This benefit is partially covered because OTC hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CORE 004 CO (HMO), with other eye exam services excluded from coverage. Routine eye exams are covered once yearly with a $0 to $25 copay, no coinsurance, and no deductible, while eligible eyewear features no copay, no coinsurance, and no deductible up to a $350 annual maximum.
Dental Services See details
DEVOTED CORE 004 CO (HMO) dental services are partially covered up to a $3,500 annual maximum, excluding maxillofacial prosthetics, implant services, and orthodontics. Medicare-covered dental services require a $25 copay and no coinsurance, while other covered preventive and comprehensive services have no copay and coinsurance ranging from 0% to 50%.
Home Infusion bundled Services See details
DEVOTED CORE 004 CO (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry a coinsurance ranging from no coinsurance up to 20%, while Part B insulin is covered with a $35 copay and up to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CORE 004 CO (HMO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Medical equipment is covered by DEVOTED CORE 004 CO (HMO) with no copays and prior authorization required, featuring 20% to 50% coinsurance for durable medical equipment. Prosthetics, medical supplies, and diabetic supplies also require no copays, with coinsurance ranging from no coinsurance up to 20% for prosthetics and up to 50% for diabetic supplies; however, diabetic equipment is only partially covered because diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CORE 004 CO (HMO), with prior authorization required for all services. Lab services, diagnostic radiology, and outpatient X-rays have no copay, diagnostic procedures range from a $0 to $95 copay with no coinsurance, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
DEVOTED CORE 004 CO (HMO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CORE 004 CO (HMO) provides coverage for Cardiac Rehabilitation Services with no coinsurance, but only some services are covered in practice. Standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered and require a $25 copay, with prior authorization required.
Skilled Nursing Facility (SNF) See details
DEVOTED CORE 004 CO (HMO) 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 three-day prior hospital stay is not required, additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
Other Services are partially covered by DEVOTED CORE 004 CO (HMO), excluding meal benefits. Covered options include unlimited acupuncture with no copay and 50% coinsurance, additional preventive services with no copay and no coinsurance, and up to $100 every three months for over-the-counter (OTC) items with no copay and no coinsurance.
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