DEVOTED GIVEBACK 002 VA (HMO)
Medicare Advantage Plan H6994-002 • 2026
DEVOTED GIVEBACK 002 VA (HMO) Medicare Advantage Plan H6994-002 • 2026
This Medicare Advantage HMO plan, identified by CMS Plan ID H6994-002, is offered by Devoted Health for the 2026 plan year. The plan uses a Health Maintenance Organization (HMO) provider network and comes with Part D prescription drug coverage.
DEVOTED GIVEBACK 002 VA Overview
Plan Overview for H6994-002-0 |
|
|---|---|
| CMS Plan ID: | H6994-002-0 |
| Plan Type: | HMO |
| Plan Year: | 2026 |
| Monthly Premium: | $0.00 Plus your Medicare Part B premium. |
| Medical Deductible: | $0.00 |
| Maximum Out-of-Pocket: | $7000.00 (In-Network) |
| Part B Give Back: | −$184.70 reduction |
| Prescription Drug Coverage: | Enhanced, $605.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Service Area: | See List |
| Enrollment (Nationwide) | 98 beneficiaries |
| Provided By: | Devoted Health |
Plan Availability
DEVOTED GIVEBACK 002 VA (H6994-002-0) is available in the following locations (click to open):
Coverage Overview for DEVOTED GIVEBACK 002 VA
This Medicare Advantage Prescription Drug (MAPD) HMO plan includes hospital, medical, and prescription drug coverage under Medicare Parts A and B. The monthly premium is $0.00, and services are generally covered when received from in-network providers, except in emergency situations. The annual Part D deductible is $605.00.
Primary care visits have a $0 copay, specialist visits come with a $55 copay, urgent care services carry a $0-$40 copay, and ambulance transportation is $0-$315 copay. These costs apply toward the annual maximum out-of-pocket (MOOP) limit of $7000.00. After this limit is reached, in-network services are fully covered.
This plan is listed by CMS under Plan ID {title_plan_id}. A summary of cost sharing is provided below.
Out-of-Pocket Costs
DEVOTED GIVEBACK 002 VA includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The table below outlines the most common in-network out-of-pocket costs associated with plan H6994-002.
This section outlines in-network costs for primary care and specialist office visits, along with related preventive services.
| Covered Service | In-Network Cost |
|---|---|
| Primary: | In-network: $0 copay |
| Specialist: | In-network: $55 copay |
This section outlines in-network costs for preventive and wellness services included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Annual wellness exam: | In-network: $0 copay |
| Telehealth benefit: | In-network: $0-$55 copay |
| Routine chiropractic: | Not covered |
| Fitness benefits: | In-network: $0 copay |
| Health education: | In-network: $0 copay |
| Counseling services: | Not covered |
| Over-the-counter drug benefits: | In-network: $0 copay |
| Health transportation (non-emergency): | Not covered |
This section outlines in-network costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Covered Service | In-Network Cost |
|---|---|
| Diagnostic radiology services: | In-network: $0-$300 copay |
| Lab services: | In-network: $0-$20 copay |
| Outpatient x-rays: | In-network: $0-$75 copay |
| Diagnostic tests and procedures: | In-network: $0-$95 copay |
This section outlines in-network costs for emergency services, urgent care, ambulance transportation, inpatient hospital stays, and skilled nursing facility care.
| Covered Service | In-Network Cost |
|---|---|
| Emergency room care: | $115 copay |
| Worldwide emergency care: | $115 copay |
| Urgent care: | $0-$40 copay |
| Inpatient hospital care: | Tier 1 | $475 per day for days 1-3 | $0 per day for days 4-90 | $0 per stay |
| Skilled Nursing Facility: | Tier 1 | $0 per day for days 1-20 | $218 per day for days 21-100 |
| Ground ambulance: | In-network: $0-$315 copay |
This section outlines in-network costs for mental health services, including outpatient therapy and inpatient psychiatric care.
| Covered Service | In-Network Cost |
|---|---|
| Outpatient individual therapy: | In-network: $50 copay |
| Outpatient group therapy: | In-network: $50 copay |
| Inpatient psychiatric hospital care: | Tier 1 | $475 per day for days 1-3 | $0 per day for days 4-90 | $0 per stay |
This section outlines in-network costs for rehabilitation services, including physical therapy, speech and language therapy, and occupational therapy.
| Covered Service | In-Network Cost |
|---|---|
| Physical therapy and speech and language therapy: | In-network: $55 copay |
| Occupational therapy: | In-network: $35 copay |
This section outlines in-network costs for medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Covered Service | In-Network Cost |
|---|---|
| Diabetes supplies: | In-network: 0%-17% coinsurance |
| Durable medical equipment: | In-network: 17% coinsurance |
| Prosthetics: | In-network: 0%-20% coinsurance |
This section outlines in-network cost sharing for chemotherapy and other Medicare Part B-covered drugs.
| Covered Service | In-Network Cost |
|---|---|
| Chemotherapy: | In-network: 0%-20% coinsurance |
| Other Part B drugs (Medicare-covered): | In-network: 0%-20% coinsurance |
This section outlines in-network cost sharing for dental services, including preventive care, exams, x-rays, cleanings, and comprehensive dental procedures.
| Covered Service | In-Network Cost |
|---|---|
| Oral exam: | In-network: $0 copay |
| Dental x-rays: | In-network: $0 copay |
| Cleaning: | In-network: $0 copay |
| Periodontics: | In-network: $0 copay |
| Endodontics: | In-network: $0 copay |
| Restorative services: | In-network: $0 copay |
| Implant services: | Not covered |
| Orthodontics: | Not covered |
| Oral/Maxillofacial surgery: | In-network: $0 copay |
This section outlines in-network cost sharing for vision services, including eye exams, eyeglasses, and contact lenses.
| Covered Service | In-Network Cost |
|---|---|
| Routine eye exam: | In-network: $0 copay |
| Contact lenses: | In-network: $0 copay |
| Eyeglass frames only: | In-network: $0 copay |
| Eyeglass lenses only: | In-network: $0 copay |
| Eyeglasses (frames & lenses): | In-network: $0 copay |
| Upgrades: | In-network: $0 copay |
This section outlines in-network cost sharing for hearing-related services, including exams, fittings, and hearing aids.
| Covered Service | In-Network Cost |
|---|---|
| Hearing exam: | In-network: $0 copay |
| Fitting/evaluation: | In-network: $0 copay |
| Prescription hearing aids: | In-network: $599-$899 copay |
| OTC hearing aids: | Not covered |
This section outlines in-network cost sharing for additional and special needs services that may be included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Adult day health services: | Not covered |
| Home-based palliative care: | Not covered |
| Personal emergency response system: | Not covered |
| Weight management programs: | In-network: $0 copay |
| Wigs for chemotherapy-related hair loss: | Not covered |
| Alternative therapies: | In-network: $0 copay |
| Massage therapy: | Not covered |
| Home/bathroom safety devices: | In-network: $0 copay |
Certain preventive services are covered 100% by DEVOTED GIVEBACK 002 VA as a Part B benefit.
Prescription Drug Coverage
DEVOTED GIVEBACK 002 VA 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 Advantage coverage.
| Basic Part D Premium: | $-28.90 |
|---|---|
| Supplemental Part D Premium: | $28.90 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | $24.56 |
| 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 $605.00 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 002 VA 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 | $3.00 copay | Coming soon |
| Preferred Brand | 21% coinsurance | Coming soon |
| Non-Preferred Drug | 25% coinsurance | Coming soon |
| Specialty Tier | 25% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Ratings
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 |
|---|---|
| 2026 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 | Plan too new to be measured |
| 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 |
What is the monthly premium for DEVOTED GIVEBACK 002 VA (HMO)?
The 2026 monthly premium is $0.00. The Medicare Part B premium is paid separately.
What is the in-network MOOP for plan H6994-002?
For 2026, the in-network maximum out-of-pocket is $7000.00. The plan pays 100% of covered in-network services beyond this amount.
What is the star rating for plan H6994-002 in 2026?
For 2026, plan H6994-002 has a CMS star rating of ★0.0 out of 5 stars.
What is the total enrollment for plan H6994-002?
Total enrollment is 98 beneficiaries based on the latest CMS data.
Is there a Part D deductible for this plan?
The Part D deductible is $605.00.
Contact Information for Devoted Health
| Contact Type | Details |
|---|---|
| Website: | Devoted Health Plan Page |
| New Members: | 1-844-978-2770 |
| Existing Members: | 1-800-338-6833 |
| Plan Address: | Devoted Health | PO Box 211037 | Eagan, MN 55121 |
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at medicare.gov.
- CMS.gov, Landscape Source Files — Last accessed May 2, 2026
- CMS.gov, Medicare Part C & D Performance — Last accessed May 2, 2026
- CMS.gov, Plan Benefits Package — Last accessed May 2, 2026
- CMS.gov, Monthly Enrollment by Contract/Plan/State/County — Last accessed May 2, 2026
Data sources and methodology documentation..
- Devoted Health (official source), http://www.devoted.com — Last accessed October 13, 2025
- CMS.gov, "Medicare Advantage Plan Fact Sheet" — Last accessed 25 May, 2025
- Medicare.gov, "Joining a plan" — Last accessed 25 May, 2025
- Medicare.gov, "Your coverage options" — Last accessed 25 May, 2025
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