DEVOTED PREMIUM 005 OR (HMO) Medicare Advantage Plan H2923-005 • 2027
- Monthly Premium
- $43.00Plus Part B premium.
- Medical Deductible
- $200
- Maximum Out-of-Pocket
- $5900.00In-network
- Part B Giveback
- Not offered
- Prescription Coverage
- Enhanced, $650.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- See List
- Total Enrollment
- 315 beneficiaries
DEVOTED PREMIUM 005 OR (HMO) Introduction
CMS Plan ID H2923-005 identifies DEVOTED PREMIUM 005 OR, a Medicare Advantage HMO plan offered by Devoted Health. The plan uses a Health Maintenance Organization (HMO) provider network and comes with prescription drug coverage. Its costs for the 2027 plan year include a $43.00 monthly premium, $200 medical deductible, and $5900.00 in-network maximum out-of-pocket. The 2027 Part D prescription drug deductible is $650.00.
Plan Benefits
Cost-sharing for DEVOTED PREMIUM 005 OR 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 H2923-005.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | In-network: $0 copay | In-network: $0 copay |
| Specialist | In-network: $40 copay | In-network: $40 copay |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | In-network: $0 copay | In-network: $0 copay |
| Telehealth benefit | In-network: $0-$45 copay | In-network: $0-$45 copay |
| Routine chiropractic | In-network: $15 copay | In-network: $15 copay |
| Fitness benefits | Coming soon | In-network: $0 copay |
| Health education | In-network: $0 copay | In-network: $0 copay |
| Counseling services | Not covered | Not covered |
| Over-the-counter drug benefits | In-network: $0 copay | In-network: $0 copay |
| Health transportation (non-emergency) | Coming soon | Not covered |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | In-network: $25-$300 copay | In-network: $0-$300 copay |
| Lab services | In-network: $0-$40 copay, 20% coinsurance | In-network: $0-$20 copay |
| Outpatient x-rays | In-network: $0-$75 copay | In-network: $0-$75 copay |
| Diagnostic tests and procedures | In-network: $0-$95 copay | In-network: $0-$95 copay |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | $130 copay | $130 copay |
| Worldwide emergency care | Coming soon | $130 copay |
| Urgent care | $0-$45 copay | $0-$45 copay |
| Inpatient hospital care | Tier 1 $445 per day for days 1-5 $0 per day for days 6-90 $0 per stay |
Tier 1 $375 per day for days 1-5 $0 per day for days 6-90 $0 per stay |
| Skilled Nursing Facility | Tier 1 $0 per day for days 1-20 $221 per day for days 21-100 |
Tier 1 $0 per day for days 1-20 $218 per day for days 21-100 |
| Ground ambulance | In-network: $0-$315 copay | In-network: $0-$315 copay |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | In-network: $40 copay | In-network: $40 copay |
| Outpatient group therapy | In-network: $40 copay | In-network: $40 copay |
| Inpatient psychiatric hospital care | Tier 1 $445 per day for days 1-5 $0 per day for days 6-90 $0 per stay |
Tier 1 $375 per day for days 1-5 $0 per day for days 6-90 $0 per stay |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | In-network: $40-$50 copay | In-network: $40-$50 copay |
| Occupational therapy | In-network: $40-$50 copay | In-network: $40-$50 copay |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | In-network: $0 copay | In-network: 0%-20% coinsurance |
| Durable medical equipment | In-network: 20%-50% coinsurance | In-network: 20% coinsurance |
| Prosthetics | In-network: 0%-20% coinsurance | In-network: 0%-20% coinsurance |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | In-network: 0%-20% coinsurance | In-network: 0%-20% coinsurance |
| Other Part B drugs (Medicare-covered) | In-network: 0%-20% coinsurance | In-network: 0%-20% coinsurance |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | In-network: $0 copay | In-network: $0 copay |
| Dental x-rays | In-network: $0 copay | In-network: $0 copay |
| Cleaning | In-network: $0 copay | In-network: $0 copay |
| Periodontics | In-network: 50% coinsurance | In-network: $0 copay |
| Endodontics | In-network: 50% coinsurance | In-network: 0%-50% coinsurance |
| Restorative services | In-network: 50% coinsurance | In-network: 0%-50% coinsurance |
| Implant services | In-network: 50% coinsurance | Not covered |
| Orthodontics | Not covered | Not covered |
| Oral/Maxillofacial surgery | In-network: 50% coinsurance | In-network: $0 copay |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | In-network: $0 copay | In-network: $0 copay |
| Contact lenses | In-network: $0 copay | In-network: $0 copay |
| Eyeglass frames only | In-network: $0 copay | In-network: $0 copay |
| Eyeglass lenses only | In-network: $0 copay | In-network: $0 copay |
| Eyeglasses (frames & lenses) | In-network: $0 copay | In-network: $0 copay |
| Upgrades | In-network: $0 copay | In-network: $0 copay |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | In-network: $0 copay | In-network: $0 copay |
| Fitting/evaluation | In-network: $0 copay | In-network: $0 copay |
| Prescription hearing aids | In-network: $399-$699 copay | In-network: $199-$499 copay |
| OTC hearing aids | Not covered | Not covered |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Not covered | Not covered |
| Home-based palliative care | Not covered | Not covered |
| Personal emergency response system | Coming soon | Not covered |
| Weight management programs | In-network: $0 copay | In-network: $0 copay |
| Wigs for chemotherapy-related hair loss | Coming soon | Not covered |
| Alternative therapies | In-network: 0%-50% coinsurance | In-network: 0%-50% coinsurance |
| Massage therapy | In-network: 50% coinsurance | In-network: 50% coinsurance |
| Home/bathroom safety devices | In-network: $0 copay | In-network: $0 copay |
Certain preventive services are covered 100% by DEVOTED PREMIUM 005 OR as a Part B benefit.
Prescription Drug Coverage
DEVOTED PREMIUM 005 OR 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: | ($12.30) |
| Supplemental Part D Premium: | $$12.30 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | $6.27 |
| 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 $650.00 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 PREMIUM 005 OR 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 | 26% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H2923)
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 | Not enough data available |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | Not enough data available |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | Not enough data available |
| Drug Safety and Accuracy of Drug Pricing |
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 PREMIUM 005 OR (H2923-005-0) is available in the following locations:
Oregon Counties Served
Frequently Asked Questions
Here are some of the most frequently asked questions about this plan (click to open).
Frequently Asked Questions About DEVOTED PREMIUM 005 OR (HMO)
How much does plan H2923-005 cost per month?
For 2027, the monthly premium is $43.00. Medicare Part B premiums apply in addition to this amount.
What is the MOOP for DEVOTED PREMIUM 005 OR in 2027?
For 2027, the in-network maximum out-of-pocket is $5900.00. The plan pays 100% of covered in-network services beyond this amount.
What is the star rating for plan H2923-005 in 2027?
The 2027 CMS star rating for DEVOTED PREMIUM 005 OR is ★3.0 out of 5.
What is the current enrollment for DEVOTED PREMIUM 005 OR?
CMS reports 315 beneficiaries enrolled in this plan.
What is the Part D deductible for plan H2923-005?
The Part D deductible is $650.00.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | CMS Version |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | CY2027 Landscape (202609.1) |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | 2027 Star Ratings Data Tables |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | PBP Benefits-2027 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | 2026-09 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Devoted Health (official source) | http://www.devoted.com | October 4, 2026 |
| CMS.gov | Medicare Advantage Plan Fact Sheet | 25 May, 2025 |
| AARP.org | The Big Choice: Original Medicare vs. Medicare Advantage | 25 May, 2025 |
| Medicare.gov | Your coverage options | 25 May, 2025 |
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