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DEVOTED CORE 004 TX (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CORE 004 TX (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 TX (HMO) in 2026, please refer to our full plan details page.
DEVOTED CORE 004 TX (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in San Antonio. This plan received an overall rating of 5 out of 5 stars in 2026.
It's important to know that DEVOTED CORE 004 TX (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 TX (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 TX (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 $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 $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 TX (HMO) Medicare plan features an annual prescription drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic drugs, members enjoy no copay for 1-month, 2-month, and 3-month supplies filled at standard pharmacies or through standard mail order. This makes essential generic medications highly affordable and accessible. For higher-tier prescriptions, including Tier 3 preferred brand, Tier 4 non-preferred drugs, and Tier 5 specialty drugs, you will pay a 25% coinsurance at standard pharmacies and standard mail order. This 25% coinsurance applies to 1-month, 2-month, and 3-month supplies for Tiers 3 and 4, and to 1-month supplies for Tier 5 specialty medications. Knowing these cost-sharing details helps you estimate your out-of-pocket prescription expenses under this plan.
Additional Benefits
The DEVOTED CORE 004 TX (HMO) plan offers comprehensive medical coverage with predictable out-of-pocket costs, featuring no copay for primary care visits and preventive services. Specialist visits require a $25 copay, while inpatient hospital stays carry a $150 daily copay for the first five days and no copay for days six through 90. Emergency room care has a $150 copay, which is waived upon admission, and outpatient hospital services range from no copay up to a $250 copay. This plan also includes valuable supplemental benefits, such as dental coverage up to a $4,000 annual limit and a $400 yearly allowance for eyewear with no copay. Routine hearing exams require a $25 copay, and home health services are covered with no copay. Additionally, members can access a $100 over-the-counter allowance every three months and skilled nursing facility care with no copay for the first 20 days.
Inpatient Hospital See details
DEVOTED CORE 004 TX (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance and a copay of $150 per day for days 1 through 5, followed by no copay for days 6 through 90. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED CORE 004 TX (HMO) with no coinsurance, featuring copays ranging from $0 to $250 for outpatient hospital services and a $150 copay per stay for observation services. Ambulatory surgical center and blood services require no copay and no coinsurance, while outpatient substance abuse sessions have a $25 copay and no coinsurance.
Partial Hospitalization See details
DEVOTED CORE 004 TX (HMO) covers partial hospitalization services with a $35 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
DEVOTED CORE 004 TX (HMO) covers ground ambulance services with a copay of up to $315 (with no copay for some trips) and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required. Transportation services are not covered, as trips to plan-approved or any health-related locations are not covered.
Emergency Services See details
DEVOTED CORE 004 TX (HMO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require no coinsurance and copays ranging from no copay to $45, while worldwide emergency services are covered up to $25,000 with a $150 copay and no coinsurance for emergency or urgent care, and a $315 copay plus 20% coinsurance for transportation.
Primary Care See details
DEVOTED CORE 004 TX (HMO) covers primary care physician services with no copay and no coinsurance, and specialist visits for a $25 copay and no coinsurance. Therapy services range from a $25 to $50 copay with no coinsurance, telehealth ranges from a $0 to $45 copay with no coinsurance, while podiatry and chiropractic services are not covered.
Preventive Services See details
DEVOTED CORE 004 TX (HMO) covers preventive services with no copay and no coinsurance, including annual physical exams and kidney disease education. Additional preventive services are partially covered with no copay and no coinsurance for fitness and nutritional benefits, while sub-services like in-home safety assessments, personal emergency response systems, and therapeutic massages are not covered.
Hearing Services See details
DEVOTED CORE 004 TX (HMO) covers one routine hearing exam per year with a $25 copay and no coinsurance, as well as unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $199 to $499 for up to two devices per year, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CORE 004 TX (HMO) since other eye exam services are not covered, but routine eye exams are covered with a $0 to $25 copay and no coinsurance. Eyewear is covered with no copay or coinsurance up to a $400 annual maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED CORE 004 TX (HMO) offers partially covered dental services up to a $4,000 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 feature no copay and either no coinsurance or up to 50% coinsurance.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by DEVOTED CORE 004 TX (HMO) with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs have a coinsurance of 0% to 20%, while Medicare Part B insulin drugs require a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under DEVOTED CORE 004 TX (HMO) with no copay and a 20% coinsurance, and prior authorization is required.
Medical Equipment See details
DEVOTED CORE 004 TX (HMO) covers medical equipment with no copays, though prior authorization is required and coinsurance ranges from no coinsurance up to 50%. This benefit is partially covered, as durable medical equipment, prosthetics, and diabetic supplies are covered, but diabetic therapeutic shoes and inserts are not.
Diagnostic and Radiological Services See details
DEVOTED CORE 004 TX (HMO) covers diagnostic and radiological services with prior authorization required. Lab services and outpatient X-rays have no copay, diagnostic procedures and tests carry a copay of $0 to $95 with no coinsurance, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
DEVOTED CORE 004 TX (HMO) covers home health services with no copay and no coinsurance. Prior authorization is required to access these covered services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED CORE 004 TX (HMO) with no copay and no coinsurance, requiring prior authorization. In practice, only some services are covered as standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by DEVOTED CORE 004 TX (HMO) with no coinsurance, requiring prior authorization and no prior three-day hospital stay. There is no copay for days 1 through 20 and a $218 copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by DEVOTED CORE 004 TX (HMO), featuring 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 other miscellaneous services are not covered under this plan.
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