DEVOTED C-SNP PLUS 004 VA (HMO C-SNP)
Available to residents of Southampton County, VA for 2026. Contract H6994, plan 004, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Southampton County
- Plan website
- Browse the DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) formulary
New for 2026. This plan has no 2025 predecessor in the CMS crosswalk.
Plan details
| Monthly premium (Part C + D) | $24.60 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $24.60? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | $975.00 |
| In-network out-of-pocket maximum | $9,250.00? |
| Drug deductible | $615.00Tier 6 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO C-SNP? |
| Special needs plan | Chronic-condition SNP |
| Contract / plan | H6994-004-0 |
| Offered by | Devoted Health |
| Parent organization | Devoted Health, Inc. |
| Formulary drugs | 3,377 |
| Formulary exception tier | 4? |
| Pharmacy search | www.devoted.com |
| Member services | (844)978-2770TTY 711 |
CMS star ratings
- Overall
- —
- Health plan (Part C)
- —
- Drug plan (Part D)
- —
Published per contract — every plan under contract H6994 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | 30% coinsurance(authorization required) |
| Other health care professional | 0%–30% coinsurance(authorization required) |
| Additional telehealth services | 0%–30% coinsurance |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | 0%–50% coinsurance(authorization required) |
| Lab services | 50% coinsurance(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | 50% coinsurance(authorization required) |
| Therapeutic radiology | 20% coinsurance(authorization required) |
| Outpatient x-rays | 50% coinsurance(authorization required) |
| Emergency and urgent care | |
| Emergency room | $115 copay |
| Urgent care | 0%–20% coinsurance |
| Worldwide emergency coverage | $0 copay · $25,000 plan limit |
| Worldwide urgent care | $0 copay · $25,000 plan limit |
| Worldwide emergency transportation | $0 copay |
| Hospital care | |
| Inpatient hospital stay | $2,230 per stay(authorization required) |
| Outpatient hospital services | 0%–50% coinsurance(authorization required) |
| Outpatient observation | 50% coinsurance(authorization required) |
| Ambulatory surgical center | 0%–50% coinsurance(authorization required) |
| Outpatient blood services | 30% coinsurance(authorization required) |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $218 per day for days 21–100(authorization required) |
| Home health care | $0 copay(authorization required) |
| Kidney dialysis | 20% coinsurance(authorization required) |
| Rehabilitation | |
| Occupational therapy | 30% coinsurance(authorization required) |
| Physical therapy and speech-language therapy | 30% coinsurance(authorization required) |
| Cardiac rehabilitation | 30% coinsurance(authorization required) |
| Pulmonary rehabilitation | 30% coinsurance(authorization required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $2,080 per stay(authorization required) |
| Outpatient mental health, individual session | 30% coinsurance(authorization required) |
| Outpatient mental health, group session | 30% coinsurance(authorization required) |
| Psychiatrist, individual session | 30% coinsurance(authorization required) |
| Psychiatrist, group session | 30% coinsurance(authorization required) |
| Partial hospitalization | 20% coinsurance(authorization required) |
| Intensive outpatient program | 20% coinsurance(authorization required) |
| Outpatient substance use, individual session | 30% coinsurance(authorization required) |
| Outpatient substance use, group session | 30% coinsurance(authorization required) |
| Opioid treatment program | 30% coinsurance(authorization required) |
| Ambulance and transportation | |
| Ground ambulance | 0%–50% coinsurance(authorization required) |
| Air ambulance | 50% coinsurance(authorization required) |
| Transportation to plan-approved locations | Not covered |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 0%–20% coinsurance(authorization required) |
| Medical supplies | 0%–20% coinsurance(authorization required) |
| Diabetes supplies | 20% coinsurance(authorization required) |
| Diabetic therapeutic shoes or inserts | $0 copay(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $15 copay(authorization required) |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | 30% coinsurance(authorization required) |
| Routine foot care | $0 copay(authorization required, limits apply) |
| Dental? | |
| Medicare-covered dental services | 30% coinsurance(authorization required) |
| Preventive dental plan limit | $3,000 plan limit every year |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | Not covered |
| Other preventive dental services | Not covered |
| Restorative services (fillings, crowns) | $0 copay(authorization required, limits apply) |
| Endodontics (root canals) | $0 copay(authorization required, limits apply) |
| Periodontics (gum disease) | $0 copay(authorization required, limits apply) |
| Dentures and other removable prosthodontics | $0 copay(authorization required, limits apply) |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | $0 copay(authorization required, limits apply) |
| Oral and maxillofacial surgery | $0 copay(authorization required, limits apply) |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay(authorization required, limits apply) |
| Vision? | |
| Eye exam (Medicare-covered) | 0%–50% coinsurance(authorization required) |
| Routine eye exam | $0 copay(authorization required, limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Eyewear plan limit | $300 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | $0 copay(limits apply) |
| Hearing? | |
| Hearing exam (Medicare-covered) | 50% coinsurance(authorization required) |
| Routine hearing exam | $0 copay(authorization required, limits apply) |
| Hearing aid fitting and evaluation | $0 copay(authorization required) |
| Hearing aids (all types) | $399–$699 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $50 allowance every three months |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | $0 copay |
| Health education | $0 copay |
| Nutritional / dietary benefit | $0 copay |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | Not covered |
| Home and bathroom safety devices | $0 copay |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | $0 copay |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | $0 copay |
| Alternative therapies | $0 copay |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $18.00 |
| Tier 2 | $19.00 |
| Tier 3 | 25% |
| Tier 4 | 31% |
| Tier 5 | 25% |
| Tier 6 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $18.00 | $18.00 | $18.00 | $54.00 | $54.00 | $54.00 |
| Tier 2: Generic | $19.00 | $19.00 | $19.00 | $57.00 | $57.00 | $57.00 |
| Tier 3: Preferred Brand | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 4: Non-Preferred Drug | 31% | 31% | 31% | 31% | 31% | 31% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 46 other VA counties
- Amelia
- Bland
- Bristol City
- Buchanan
- Caroline
- Charles City
- Chesterfield
- Colonial Heights City
- Craig
- Danville City
- Dickenson
- Dinwiddie
- Emporia City
- Essex
- Floyd
- Franklin City
- Galax City
- Giles
- Goochland
- Grayson
- Greensville
- Halifax
- Hanover
- Henrico
- Henry
- Hopewell City
- King and Queen
- King William
- Lee
- New Kent
- Norton City
- Nottoway
- Patrick
- Petersburg City
- Powhatan
- Prince George
- Pulaski
- Richmond City
- Russell
- Scott
- Smyth
- Surry
- Sussex
- Washington
- Wise
- Wythe
Benefits in plain text
DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) (H6994-004-0) is a 2026 HMO C-SNP Medicare Advantage plan offered by Devoted Health, available to residents of Southampton County, VA.
The monthly premium is $24.60 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
The in-network deductible for health services is $975.00.
Its in-network out-of-pocket maximum is $9,250.00.
The drug deductible is $615.00. Tier 6 exempt.
It is a special needs plan (Chronic-condition SNP).
The plan's formulary lists 3,377 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $18.00; tier 2: $19.00; tier 3: 25%; tier 4: 31%; tier 5: 25%; tier 6: $0.00.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.