Devoted Health Advance (HMO C-SNP) is a Medicare Advantage (Part C) Special Needs Plan by Devoted Health.
This page features plan details for 2022 Devoted Health Advance (HMO C-SNP) H8173 – 010 – 0 available in Yavapai.
Devoted Health Advance (HMO C-SNP) is offered in the following locations.
Devoted Health Advance (HMO C-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Chronic or Disabling Condition |
| Conditions Covered: |
| Insurer: | Devoted Health |
| Health Plan Deductible: | $0 |
| MOOP: | $3,400 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Devoted Health Advance (HMO C-SNP) ?
| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $0.00 | $0.00 | $0.00 | $170.10 |
Devoted Health Advance (HMO C-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | Few Generics |
| Formulary Link: | Formulary Link |
| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) * | $0.00 copay | $0.00 copay | ||
| 2 (Generic) * | $0.00 copay | $0.00 copay |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) * | $0.00 copay | $0.00 copay | ||
| 2 (Generic) * | $0.00 copay | $0.00 copay |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Devoted Health Advance (HMO C-SNP) also provides the following benefits.
| In-Network: No |
| Diagnostic services: | $0 copay (limits may apply) (authorization required) |
| Endodontics: | $0 copay (limits may apply) (authorization required) |
| Extractions: | $0 copay (limits may apply) (authorization required) |
| Non-routine services: | $0 copay (limits may apply) (authorization required) |
| Periodontics: | $0 copay (limits may apply) (authorization required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0 copay (limits may apply) (authorization required) |
| Restorative services: | $0 copay (limits may apply) (authorization required) |
| Cleaning: | $0 copay (limits may apply) |
| Dental x-ray(s): | $0 copay (limits may apply) |
| Fluoride treatment: | $0 copay (limits may apply) |
| Oral exam: | $0 copay (limits may apply) |
| Diagnostic radiology services (e.g., MRI): | $0-175 copay (authorization required) (referral required) |
| Diagnostic tests and procedures: | $0-25 copay (authorization required) |
| Lab services: | $0 copay (authorization required) |
| Outpatient x-rays: | $0-15 copay (authorization required) (referral required) |
| Primary: | $0 copay |
| Specialist: | $0-15 copay per visit |
| Emergency: | $120 copay per visit (always covered) |
| Urgent care: | $0-15 copay per visit (always covered) |
| Foot exams and treatment: | $0 copay |
| Routine foot care: | $0 copay |
| $225 copay |
| $0.00 |
| In-Network: No |
| Fitting/evaluation: | $0 copay |
| Hearing aids: | $399-699 copay (limits may apply) |
| Hearing exam: | $15 copay |
| $175 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) |
| $0-175 copay per visit (authorization required) |
| $3,400 In-network |
| Diabetes supplies: | $0 copay (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 0-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 0-20% coinsurance per item (authorization required) |
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 0-20% coinsurance (authorization required) |
| Inpatient hospital – psychiatric: | $175 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | $0-15 copay (authorization required) |
| Outpatient group therapy visit: | $0-15 copay (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | $0-15 copay (authorization required) |
| Outpatient individual therapy visit: | $0-15 copay (authorization required) |
| No |
| $0 copay |
| Occupational therapy visit: | $10-20 copay (referral required) |
| Physical therapy and speech and language therapy visit: | $10-20 copay (authorization required) (referral required) |
| $0 per day for days 1 through 20 $184 per day for days 21 through 40 $0 per day for days 41 through 100 (authorization required) |
| $0 copay (limits may apply) |
| Contact lenses: | $0 copay (limits may apply) |
| Eyeglass frames: | $0 copay (limits may apply) |
| Eyeglass lenses: | $0 copay (limits may apply) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) |
| Other: | Not covered |
| Routine eye exam: | $0 copay (limits may apply) |
| Upgrades: | $0 copay (limits may apply) |
| Covered |
Ready to sign up for Devoted Health Advance (HMO C-SNP) ?
Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
SMID: MULTIPLAN_HCIHNDOGMED01_M
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