DEVOTED GIVEBACK EXTRAS 026 MO (HMO) Medicare Advantage Plan H2041-026 • 2027
- Monthly Premium
- $0.00Plus Part B premium.
- Medical Deductible
- $150
- Maximum Out-of-Pocket
- $5200.00In-network
- Part B Giveback
- −$80.00 reduction
- Prescription Coverage
- Enhanced, $700.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- See List
- Total Enrollment
- 0 beneficiaries
DEVOTED GIVEBACK EXTRAS 026 MO (HMO) Introduction
DEVOTED GIVEBACK EXTRAS 026 MO is a Medicare Advantage HMO plan offered by Devoted Health. It uses a Health Maintenance Organization (HMO) provider network and comes with prescription drug coverage. For the 2027 plan year it has a $0.00 monthly premium, $150 medical deductible, and $5200.00 in-network maximum out-of-pocket. CMS Plan ID H2041-026 identifies this plan. The 2027 Part D prescription drug deductible is $700.00.
Plan Benefits
Cost-sharing for DEVOTED GIVEBACK EXTRAS 026 MO includes out-of-pocket expenses for covered healthcare services. The following tables provide a summary of typical in-network out-of-pocket costs for plan H2041-026.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | In-network: $0 copay | Coming soon |
| Specialist | In-network: $45 copay | Coming soon |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | In-network: $0 copay | Coming soon |
| Telehealth benefit | In-network: $0-$50 copay | Coming soon |
| Routine chiropractic | Not covered | Coming soon |
| Fitness benefits | Coming soon | Coming soon |
| Health education | In-network: $0 copay | Coming soon |
| Counseling services | Not covered | Coming soon |
| Over-the-counter drug benefits | In-network: $0 copay | Coming soon |
| Health transportation (non-emergency) | Coming soon | Coming soon |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | In-network: $25-$300 copay | Coming soon |
| Lab services | In-network: $0-$45 copay, 20% coinsurance | Coming soon |
| Outpatient x-rays | In-network: $0-$75 copay | Coming soon |
| Diagnostic tests and procedures | In-network: $0-$95 copay | Coming soon |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | $130 copay | Coming soon |
| Worldwide emergency care | Coming soon | Coming soon |
| Urgent care | $0-$50 copay | Coming soon |
| Inpatient hospital care | Tier 1 $410 per day for days 1-7 $0 per day for days 8-90 $0 per stay |
Coming soon |
| Skilled Nursing Facility | Tier 1 $10 per day for days 1-20 $221 per day for days 21-100 |
Coming soon |
| Ground ambulance | In-network: $0-$325 copay | Coming soon |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | In-network: $45 copay | Coming soon |
| Outpatient group therapy | In-network: $45 copay | Coming soon |
| Inpatient psychiatric hospital care | Tier 1 $410 per day for days 1-7 $0 per day for days 8-90 $0 per stay |
Coming soon |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | In-network: $45-$50 copay | Coming soon |
| Occupational therapy | In-network: $45-$50 copay | Coming soon |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | In-network: $0 copay | Coming soon |
| Durable medical equipment | In-network: 20%-50% coinsurance | Coming soon |
| Prosthetics | In-network: 0%-20% coinsurance | Coming soon |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | In-network: 0%-20% coinsurance | Coming soon |
| Other Part B drugs (Medicare-covered) | In-network: 0%-20% coinsurance | Coming soon |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | In-network: $0 copay | Coming soon |
| Dental x-rays | In-network: $0 copay | Coming soon |
| Cleaning | In-network: $0 copay | Coming soon |
| Periodontics | In-network: 50% coinsurance | Coming soon |
| Endodontics | In-network: 50% coinsurance | Coming soon |
| Restorative services | In-network: 50% coinsurance | Coming soon |
| Implant services | In-network: 50% coinsurance | Coming soon |
| Orthodontics | Not covered | Coming soon |
| Oral/Maxillofacial surgery | In-network: 50% coinsurance | Coming soon |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | In-network: $0 copay | Coming soon |
| Contact lenses | In-network: $0 copay | Coming soon |
| Eyeglass frames only | In-network: $0 copay | Coming soon |
| Eyeglass lenses only | In-network: $0 copay | Coming soon |
| Eyeglasses (frames & lenses) | In-network: $0 copay | Coming soon |
| Upgrades | In-network: $0 copay | Coming soon |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | In-network: $0 copay | Coming soon |
| Fitting/evaluation | In-network: $0 copay | Coming soon |
| Prescription hearing aids | In-network: $599-$899 copay | Coming soon |
| OTC hearing aids | Not covered | Coming soon |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Not covered | Coming soon |
| Home-based palliative care | Not covered | Coming soon |
| Personal emergency response system | Coming soon | Coming soon |
| Weight management programs | In-network: $0 copay | Coming soon |
| Wigs for chemotherapy-related hair loss | Coming soon | Coming soon |
| Alternative therapies | In-network: $0 copay | Coming soon |
| Massage therapy | Not covered | Coming soon |
| Home/bathroom safety devices | In-network: $0 copay | Coming soon |
Certain preventive services are covered 100% by DEVOTED GIVEBACK EXTRAS 026 MO as a Part B benefit.
Prescription Drug Coverage
DEVOTED GIVEBACK EXTRAS 026 MO includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.
This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | ($11.90) |
| Supplemental Part D Premium: | $$11.90 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | $18.38 |
| Low-Income Premium Subsidy Paid by CMS: | $0.00 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $700.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Devoted Health starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, DEVOTED GIVEBACK EXTRAS 026 MO may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | Coming soon |
| Generic | $2.00 copay | Coming soon |
| Preferred Brand | 25% coinsurance | Coming soon |
| Non-Preferred Drug | 25% coinsurance | Coming soon |
| Specialty Tier | 25% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H2041)
CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | Plan too new to be measured |
| Managing Chronic (Long Term) Conditions | Plan too new to be measured |
| Member Experience with Health Plan | Plan too new to be measured |
| Complaints and Changes in Plans Performance | Plan too new to be measured |
| Health Plan Customer Service | Plan too new to be measured |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | Plan too new to be measured |
| Member Experience with the Drug Plan | Plan too new to be measured |
| Drug Safety and Accuracy of Drug Pricing | Plan too new to be measured |
Contact Information for Devoted Health
- Website
- Devoted Health Plan Page
- Providers
- Devoted Health Providers Page
- Formulary
- Devoted Health Formulary Page
- Pharmacy
- Devoted Health Pharmacy Page
- New Member Health Plan Help
- (844)978-2770
- New Member Health Plan TTY
- 711
- New Member Part D Help
- (844)978-2770
- New Member Part D TTY Users
- 711
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Plan Availability
DEVOTED GIVEBACK EXTRAS 026 MO (H2041-026-0) is available in the following locations:
Frequently Asked Questions
Here are some of the most frequently asked questions about this plan (click to open).
Frequently Asked Questions About DEVOTED GIVEBACK EXTRAS 026 MO (HMO)
Is there a monthly premium for this plan in 2027?
The 2027 monthly premium is $0.00. The Medicare Part B premium is paid separately.
What is the in-network MOOP for plan H2041-026?
The 2027 in-network MOOP is $5200.00. Once this limit is reached, covered in-network costs are fully covered.
What is the CMS star rating for this plan?
The 2027 CMS star rating for DEVOTED GIVEBACK EXTRAS 026 MO is ★0.0 out of 5.
What is the current enrollment for DEVOTED GIVEBACK EXTRAS 026 MO?
CMS reports 0 beneficiaries enrolled in this plan.
What is the prescription drug deductible for 2027?
The plan’s Part D deductible is $700.00, applied to covered prescription drug costs.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Devoted Health (official source) | http://www.devoted.com | October 4, 2026 |
| Medicare.gov | Compare types of Medicare Advantage Plans | 25 May, 2025 |
| Medicare.gov | Joining a plan | 25 May, 2025 |
| Medicare.gov | Explore your Medicare coverage options | 25 May, 2025 |
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Page content independently curated and maintained by David W. Bynon, Editorial Steward, using a standardized, data-driven methodology for accurate, non-commercial Medicare plan interpretation and resolution.