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DEVOTED CORE 004 TN (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CORE 004 TN (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 TN (HMO) in 2026, please refer to our full plan details page.
DEVOTED CORE 004 TN (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Memphis. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that DEVOTED CORE 004 TN (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 TN (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 TN (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 $375.00 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 $4900.00 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 TN (HMO) Medicare plan features an annual drug deductible of $375. For Tier 1 preferred generic and Tier 2 generic drugs, members enjoy no copay for one-month, two-month, and three-month supplies filled through standard pharmacies or standard mail order. This makes managing everyday prescription medications highly affordable. For higher-tier medications, cost sharing is based on coinsurance percentages rather than flat copayments. Tier 3 preferred brand drugs carry a 24% coinsurance, while Tier 4 non-preferred drugs require a 25% coinsurance for standard pharmacy and standard mail-order fills. Specialty drugs in Tier 5 are covered with a 28% coinsurance for a one-month supply.
Additional Benefits
The DEVOTED CORE 004 TN (HMO) plan offers affordable access to essential medical care, featuring no copay for primary care visits and annual physicals, alongside a $25 copay for specialist visits. For hospital stays, members pay a $295 daily copay for the first five days and no copay for subsequent days up to day 90, while emergency room visits carry a $130 copay that is waived upon admission. Outpatient surgical services and home health care are also available with no copay, helping to keep your out-of-pocket medical costs low. Dental coverage is a major highlight, providing up to a $4,000 annual maximum with no copay for preventive care and up to 50% coinsurance for restorative services. Vision benefits include a routine eye exam with a copay up to $25 and a $350 annual eyewear allowance, while hearing services offer routine exams for a $25 copay and prescription hearing aids with copays ranging from $399 to $699. Additionally, the plan includes a $100 over-the-counter allowance every three months, though durable medical equipment requires a 20% to 50% coinsurance.
Inpatient Hospital See details
DEVOTED CORE 004 TN (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $295 daily copay for days 1 through 5 and no copay for days 6 through 90. Unlimited additional days are covered for acute care, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED CORE 004 TN (HMO) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and blood services. Medicare-covered outpatient hospital services carry a copay ranging from no copay to $395, while observation services require a $295 copay per stay and outpatient substance abuse sessions have a $25 copay.
Partial Hospitalization See details
DEVOTED CORE 004 TN (HMO) covers partial hospitalization with a $60.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance services under DEVOTED CORE 004 TN (HMO) require prior authorization, with ground ambulance services carrying a copay of no copay to $315 and air ambulance services requiring a 20% coinsurance and no copay. Transportation services to health-related locations are not covered.
Emergency Services See details
DEVOTED CORE 004 TN (HMO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services feature a copay ranging from no copay up to $45 with no coinsurance, while worldwide emergency services are covered up to a $25,000 limit with a $130 copay and no coinsurance for emergency or urgent care, and a $315 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
Primary care benefits are covered by DEVOTED CORE 004 TN (HMO) with no copay and no coinsurance for primary care visits, and a $25 copay and no coinsurance for specialists. Physical, occupational, and speech therapies require a $25 to $50 copay and no coinsurance, mental health services have a $25 copay and no coinsurance, while podiatry and routine chiropractic care are not covered.
Preventive Services See details
Preventive Services are partially covered by DEVOTED CORE 004 TN (HMO) with no copay and no coinsurance for covered care, such as annual physical exams and fitness benefits. However, sub-services like in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, remote access, and counseling are not covered.
Hearing Services See details
Hearing Services are partially covered by DEVOTED CORE 004 TN (HMO), offering routine exams for a $25 copay and no coinsurance, and prescription hearing aids with no coinsurance and a copay between $399 and $699. However, 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 TN (HMO), offering one routine eye exam per year with a $0 to $25 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible up to a $350 annual maximum for contacts, lenses, frames, and upgrades.
Dental Services See details
DEVOTED CORE 004 TN (HMO) offers partially covered dental services up to a $4,000 annual maximum, featuring no copay and no coinsurance for preventive care, and no copay with 0% to 50% coinsurance for restorative services, endodontics, and prosthodontics. Medicare-covered dental services require a $25 copay and no coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CORE 004 TN (HMO) covers home infusion bundled services with no copay, subject to prior authorization and step therapy. Associated Medicare Part B drugs, including chemotherapy and insulin, require a coinsurance ranging from no coinsurance to 20%, with insulin also carrying a $35 copay.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED CORE 004 TN (HMO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED CORE 004 TN (HMO) with no copays and required prior authorization for all covered services. Durable medical equipment carries a 20% to 50% coinsurance, prosthetics and medical supplies range from no coinsurance to 20% coinsurance, and diabetic supplies range from no coinsurance to 50% coinsurance, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED CORE 004 TN (HMO) with prior authorization required. Lab services and outpatient X-rays have no copay, diagnostic procedures and tests have no coinsurance and a copay ranging from $0 to $95, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the DEVOTED CORE 004 TN (HMO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED CORE 004 TN (HMO) covers cardiac rehabilitation services with no coinsurance and prior authorization, but some services are covered while standard cardiac, intensive cardiac, pulmonary, and SET for PAD services are not covered and require a $25 copay.
Skilled Nursing Facility (SNF) See details
DEVOTED CORE 004 TN (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 prior 3-day hospital stay is not needed, additional days beyond the standard 100 days are not covered.
Other Services See details
DEVOTED CORE 004 TN (HMO) partially covers other services, offering Over-the-Counter (OTC) items up to $100 every three months and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and Dual Eligible SNPs with Highly Integrated Services are not covered under this benefit.
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