DEVOTED CORE 004 HI H5397-004 (HMO)

DEVOTED CORE 004 HI (HMO) is a Medicare Advantage plan that the current plan record identifies as including Part D prescription drug coverage. The plan record also identifies Part D prescription drug coverage. Its published drug benefit lists 5 formulary tiers. Published supplemental benefits include dental ($3,000/yr preventive dental allowance), vision ($350/yr eyewear allowance), hearing ($399–$699 copay per hearing aid), and over-the-counter (OTC) ($50/quarter OTC allowance). Review the plan documents for covered services, limits, and rules. Coverage can change each plan year.

The published 2026 monthly plan premium for DEVOTED CORE 004 HI (HMO) is $0. The standard Part B premium is $202.90/month in 2026 for most people; assistance may pay it for some members. The listed Part D deductible is $475. The in-network medical out-of-pocket maximum is $6,200; it does not include Part D drug spending. Published visit costs include primary care $0 and specialist visits $40. These figures are plan data, not a personal yearly-cost estimate.

CMS lists DEVOTED CORE 004 HI (HMO) as a HMO plan. A network label alone does not confirm that a specific doctor participates. Use the doctor lookup tool, then confirm with the doctor's office and the plan before receiving care. Provider networks and member costs can change. Emergency care and travel coverage can follow different network rules.

DEVOTED CORE 004 HI (HMO) has 5 published formulary tiers in the current plan record. Published preferred-pharmacy 30-day retail costs include Tier 1 at $0, Tier 2 at $0, Tier 3 at 22%, Tier 4 at 25%, and Tier 5 at 27%. The listed Part D deductible is $475. A tier listing does not confirm that a specific prescription is covered. Check each medication against the plan's current formulary, restrictions, pharmacy network, and costs before enrolling.

The current plan record for DEVOTED CORE 004 HI (HMO) lists dental ($3,000/yr preventive dental allowance), vision ($350/yr eyewear allowance), and hearing ($399–$699 copay per hearing aid). It also lists over-the-counter (OTC) ($50/quarter OTC allowance). Benefit allowances, frequency, eligibility, and participating providers can have additional limits, so review the Summary of Benefits or Evidence of Coverage for the complete rules.

DEVOTED CORE 004 HI (HMO) is a 2026 Medicare Advantage plan. The Annual Enrollment Period runs from October 15 through December 7, with changes taking effect January 1. The Medicare Advantage Open Enrollment Period runs from January 1 through March 31 for people already enrolled in Medicare Advantage. A qualifying circumstance may create a Special Enrollment Period outside those dates. Confirm the enrollment window and effective date that apply to you before changing coverage.