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Devoted EXTRA San Antonio (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted EXTRA San Antonio (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted EXTRA San Antonio (HMO) in 2025, please refer to our full plan details page.
Devoted EXTRA San Antonio (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 4.5 out of 5 stars in 2025.
It's important to know that Devoted EXTRA San Antonio (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 EXTRA San Antonio (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 EXTRA San Antonio (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 $590.00 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 $4150.00 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 EXTRA San Antonio (HMO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590.00. During the initial coverage phase, after you meet your deductible, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. Preferred Generic drugs have no copay at either a standard or mail pharmacy. Standard Generic, Preferred Brand, and Non-Preferred drugs have a 25% coinsurance at both standard and mail pharmacies. After your yearly out-of-pocket drug costs reach $2000.00, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Devoted EXTRA San Antonio (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $150 copay for the first few days, while outpatient services and primary care visits have copays that range from $0-$25. The plan also includes coverage for hearing, vision, and dental services, with copays for exams and maximum annual benefits for eyewear and dental work. Additional benefits include coverage for ambulance services, emergency services, and home health services, with some services having copays or coinsurance. Preventive services, such as annual physical exams, are covered with no copay. However, the plan does not cover cardiac rehabilitation, and other services such as over-the-counter items and certain types of care are not covered.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you pay a $150 copay for days 1-5, and no copay for days 6-90; additional days are covered with no copay. For Inpatient Hospital Psychiatric, you pay a $150 copay for days 1-5, and no copay for days 6-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered, including all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $250, observation services have a $150 copay, and ambulatory surgical center services have no copay. Individual and group sessions for outpatient substance abuse have a $25 copay, and outpatient blood services include a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted EXTRA San Antonio (HMO) plan, with a $35 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted EXTRA San Antonio (HMO) plan. Ground ambulance services have a copay of $0-$275, while air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Devoted EXTRA San Antonio (HMO) plan. Emergency Services have a $140 copay, Urgently Needed Services have a copay between $0 and $45, and Worldwide Emergency Coverage has a $140 copay, Worldwide Urgent Coverage has a $140 copay, and Worldwide Emergency Transportation has a $275 copay and 20% coinsurance, with a maximum plan benefit coverage of $25,000.
Primary Care See details
The Devoted EXTRA San Antonio (HMO) plan covers primary care physician services, chiropractic services, occupational therapy, physician specialist services, mental health specialty services, other health care professionals, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $20 copay, while occupational therapy services have a copay between $0 and $50. Physician specialist services and additional telehealth benefits have a copay between $0 and $25. Individual and group sessions for mental health specialty services, psychiatric services, and opioid treatment program services have a $25 copay. Physical therapy and speech-language pathology services have a copay between $0 and $50. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams, health education, Personal Emergency Response System (PERS), weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, Home and Bathroom Safety Devices and Modifications, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit, with no copay or coinsurance for covered services. In-home safety assessments, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, and counseling services are not covered.
Hearing Services See details
Hearing services include hearing exams with a $25 copay, and prescription hearing aids with a copay between $199 and $499. Routine hearing exams are covered for 1 visit every year, and fitting/evaluation for hearing aids are unlimited. Prescription hearing aids (inner ear, outer ear, and over the ear) and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $25 copay, and coverage for eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, with a combined maximum benefit of $1,000 every year. Routine eye exams are covered once per year.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $25 copay, along with other dental services such as oral exams, dental x-rays, and more. The plan has a $1,000 maximum benefit per year, and some services like maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. The plan has a $35 copay and 20% coinsurance for Medicare Part B Insulin Drugs, and a coinsurance between 0% and 20% for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs.
Dialysis Services See details
Dialysis Services are covered by the Devoted EXTRA San Antonio (HMO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance between 0% and 50%, Prosthetic Devices with a coinsurance between 0% and 20%, and Medical Supplies with a 20% coinsurance, all with no copay. However, Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures and tests with a copay between $0 and $95, lab services with no copay, and outpatient x-ray services with no copay. Therapeutic Radiological Services have a coinsurance of at most 20%, and Diagnostic Radiological Services have a copay of at most $300.
Home Health Services See details
Home Health Services are covered by the Devoted EXTRA San Antonio (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted EXTRA San Antonio (HMO) plan. The plan does not cover any services related to cardiac rehabilitation, including intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted EXTRA San Antonio (HMO) plan, but require prior authorization. For days 1-20, there is no copay, but for days 21-100, there is a $214 copay. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services, including acupuncture, over-the-counter items, meal benefits, and Dual Eligible SNPs with Highly Integrated Services are not covered. Other services, such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are also not covered.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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