DEVOTED C-SNP PREMIUM 020 PA (HMO C-SNP)

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$32.70
Monthly Premium

DEVOTED C-SNP PREMIUM 020 PA (HMO C-SNP) is a HMO C-SNP plan offered by Devoted Health

Plan ID: H6852-020

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.

Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.

Learn more about Medicare Advantage plans such as DEVOTED C-SNP PREMIUM 020 PA (HMO C-SNP) - H6852-020 by Devoted Health as well as other Medicare Advantage plans available in your area.

$32.70
Monthly Premium

Pennsylvania Counties Served

AlleghenyArmstrongBeaverBedfordBlairButlerCambriaFultonGreeneHuntingdonIndianaSomersetWashingtonWestmoreland

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $615
Out of Pocket Max In-Network: $7000
Out-of-Network: N/A
Initial Coverage Limit $0
Catastrophic Coverage Limit $2100
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $35
Prior Authorization Required for Doctor Specialty Visit
Cost share applies to wound care services, facet injections, cortisol injections, and specialist services.
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$320 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
Urgent Care

Urgent Care:
Copayment for Urgent Care $0 to $40

The min cost share applies to urgently needed services received by a PCP. The max cost share applies to urgently needed services received from an urgent care center.

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $115
Maximum Plan Benefit of $25,000
Emergency Room Visit

Emergency Care:
Copayment for Emergency Care $115
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $115
Copayment for Worldwide Emergency Transportation (Ground) $315
Maximum Plan Benefit of $25,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $0 to $315
Cost share applies per trip. Min cost share for facility to facility transfers. Max cost share for all other ambulance services.

Air Ambulance:
Coinsurance for Air Ambulance Services $20%
Prior Authorization Required for Air Ambulance
Cost share applies per trip.

Health Care Services and Medical Supplies

DEVOTED C-SNP PREMIUM 020 PA (HMO C-SNP) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Prior Authorization Required for Chiropractic Services
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0
Durable Medical Equipment (DME)
In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $95
Copayment for Medicare-covered Lab Services $0 to $20
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Cost share varies based on site of service:PCPs office: No cost share for EKGs/EEGs/ECGs, no cost share all other. Specialist office: No cost share for EKGs/EEGs/ECGs, $40 copay all other. Freestanding facility: $40 copay for EKGs/EEGs/ECGs, $40 copay all other. Outpatient hospital: $95 copay for EKGs/EEGs/ECGs, $95 copay all other. No cost share for home sleep studies. No cost share for remote patient monitoring services.

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $300
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $75
Home Health Care
In-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$320 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Mental Health Outpatient Care
In-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $35
Copayment for Medicare-covered Group Sessions $35
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $420
Prior Authorization Required for Outpatient Hospital Services
The min cost share applies to diagnostic colonoscopies, the max cost share applies to all other outpatient hospital services.

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $320
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $320
Prior Authorization Required for Ambulatory Surgical Center Services
The min cost share applies to diagnostic colonoscopies, the max cost share applies to all other ASC services.
Outpatient Substance Abuse Care
In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $35
Copayment for Medicare-covered Group Sessions $35
Prior Authorization Required for Outpatient Substance Abuse Services
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $50.00 every three months for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $50 every three months
Podiatry Services
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $35
Copayment for Routine Foot Care $35
  • Maximum 4 visits every year
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$218 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Medicare Covered Preventive Dental:
Copayment for Office Visit $35
Prior Authorization Required for Medicare Covered Preventive Dental

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
  • Maximum plan benefit of $2,000 every year for Non-medicare preventive
Copayment for Oral exams $0
  • Maximum 2 visits (Please see Evidence of Coverage for details)
Copayment for Dental x-rays $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prophylaxis $0
  • Maximum 2 visits (Please see Evidence of Coverage for details)
Copayment for Fluoride treatment $0
  • Maximum 2 visits (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $2,000 every year

Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
  • Maximum plan benefit of $2,000 every year for Non-medicare comprehensive
Copayment for Restorative services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prothodontics, removable $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prothodontics, fixed $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Maxillofacial surgery $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Adjunctive general services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum plan benefit of $2,000 every year

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $35
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exams every year
Prior Authorization Required for Eye Exams
The min cost share applies to diabetic retinopathy exams. The max cost share applies to other Medicare-covered eye exams.

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
Copayment for Eyeglasses (lenses and frames) $0
Copayment for Eyeglass Lenses $0
Copayment for Eyeglass Frames $0
Copayment for Upgrades $0
Maximum Plan Benefit of $300 every year

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $35
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $399 to $699
  • Maximum 2 Hearing Aids every year

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit

Prescription Drug Costs and Coverage

The DEVOTED C-SNP PREMIUM 020 PA (HMO C-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $615 (excludes Tiers 6) per year.

Coverage Cost
Coverage & Cost
Annual Drug Deductible $615 (excludes Tiers 6)
Select Care Drugs
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $615 (excludes Tiers 6)
Select Care Drugs
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $615 (excludes Tiers 6)
Select Care Drugs
  • Standard retail $0.00
  • Standard mail order $0.00
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