DEVOTED C-SNP GIVEBACK EXTRAS 025 OH (HMO C-SNP) H2697-025 • 2027 • Auglaize County, OH
- Monthly Premium
- $0.00Plus Part B premium.
- Medical Deductible
- $150
- Maximum Out-of-Pocket
- $6400.00In-network
- Part B Giveback
- −$110.00 reduction
- Prescription Coverage
- Enhanced, $700.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- Auglaize County, OH
- Local Enrollment
- 0 beneficiaries in Auglaize County
Introduction
CMS Plan ID H2697-025 identifies DEVOTED C-SNP GIVEBACK EXTRAS 025 OH, a Medicare Advantage Chronic Condition Special Needs Plan (C-SNP) offered by Devoted Health. Its provider network is a Health Maintenance Organization (HMO), and Medicare Part D prescription drug coverage is included. For 2027, the plan has a $0.00 monthly premium, $150 medical deductible, and $6400.00 in-network maximum out-of-pocket. The 2027 Part D prescription drug deductible is $700.00.
Enrollment in this plan requires you to live in Auglaize County, Ohio. CMS reports 0 beneficiaries enrolled in this plan in Auglaize County. New members can call the plan directly at (844)978-2770 (TTY 711) for assistance.
Eligibility
DEVOTED C-SNP GIVEBACK EXTRAS 025 OH is a Chronic Condition Special Needs Plan (C-SNP) designed for people with qualifying health conditions.
- Special Needs Plan Type
- Chronic Condition Special Needs Plan (C-SNP)
- Medicare Requirement
- Must have Medicare Part A and Part B
- Special Needs Requirement
- This plan is for individuals with cardiovascular disorders, chronic heart failure, and/or diabetes mellitus.
- Service Area Requirement
- Must live in the plan's service area
- Prescription Drug Coverage
- Medicare Part D prescription drug coverage is included.
Compare Similar Plans in Auglaize County
Compare this plan with the two most-enrolled HMO C-SNP plans available in Auglaize County, Ohio. Enrollment is based on CMS local enrollment data.
| Plan Detail | DEVOTED C-SNP GIVEBACK EXTRAS 025 OH | Aetna Medicare Chronic Care | Aetna Medicare Chronic Care Total |
|---|---|---|---|
| CMS Plan ID | H2697-025-0 |
H0628-039-0 |
H0628-034-0 |
| Local Enrollment | 0 | 38 | 19 |
| Monthly Premium | $0.00 | $0.00 | $0.00 |
| Medical Deductible | $150 | $0.00 | $0.00 |
| Maximum Out-of-Pocket | $6,400.00 | $7,150.00 | $9,850.00 |
| Part B Giveback | −$110.00 reduction | Not offered | Not offered |
| Primary Care | $0 copay | $0 copay | $0 copay |
| Specialist | $45 copay | $0-$30 copay | 0%-20% coinsurance |
| Part D Deductible | $700.00 | $700.00 | $700.00 |
| CMS Star Rating | Not yet rated | Not yet rated | Not yet rated |
| Dental | $0 copay | $0 copay | $0 copay |
| Vision | $0 copay | $0 copay | $0 copay |
| Hearing | $0 copay | $0 copay | $0 copay |
Plan Benefits
DEVOTED C-SNP GIVEBACK EXTRAS 025 OH has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The tables below detail the most common in-network out-of-pocket expenses for plan H2697-025.
You can also compare 2027 costs and coverage with last year, side-by-side: Plan H2697-025-0 Cost Compare.
Office Visits
- Primary care
- In-network: $0 copay
- Specialist
- In-network: $45 copay
Preventive and Wellness Services
- Annual wellness exam
- In-network: $0 copay
- Telehealth benefit
- In-network: $0-$50 copay
- Routine chiropractic
- Not covered
- Fitness benefits
- Coming soon
- Health education
- In-network: $0 copay
- Counseling services
- Not covered
- Over-the-counter drug benefits
- In-network: $0 copay
- Health transportation (non-emergency)
- Coming soon
Diagnostic, Lab, and Imaging Services
- Diagnostic radiology services
- In-network: $25-$300 copay
- Lab services
- In-network: $0-$45 copay, 20% coinsurance
- Outpatient x-rays
- In-network: $0-$75 copay
- Diagnostic tests and procedures
- In-network: $0-$95 copay
Emergency and Urgent Care Services
- Emergency room care
- $130 copay
- Worldwide emergency care
- Coming soon
- Urgent care
- $0-$50 copay
- Inpatient hospital care
- Tier 1
$550 per day for days 1-5
$0 per day for days 6-90
$0 per stay - Skilled Nursing Facility
- Tier 1
$10 per day for days 1-20
$221 per day for days 21-100 - Ground ambulance
- In-network: $0-$325 copay
Mental Health Services
- Outpatient individual therapy
- In-network: $45 copay
- Outpatient group therapy
- In-network: $45 copay
- Inpatient psychiatric hospital care
- Tier 1
$550 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Rehabilitation Services
- Physical therapy and speech and language therapy
- In-network: $45-$50 copay
- Occupational therapy
- In-network: $45-$50 copay
Medical Equipment and Supplies
- Diabetes supplies
- In-network: $0 copay
- Durable medical equipment
- In-network: 20%-50% coinsurance
- Prosthetics
- In-network: 0%-20% coinsurance
Medicare Part B Drugs
- Chemotherapy
- In-network: 0%-20% coinsurance
- Other Part B drugs (Medicare-covered)
- In-network: 0%-20% coinsurance
Dental Services
- Oral exam
- In-network: $0 copay
- Dental x-rays
- In-network: $0 copay
- Cleaning
- In-network: $0 copay
- Periodontics
- In-network: 50% coinsurance
- Endodontics
- In-network: 50% coinsurance
- Restorative services
- In-network: 50% coinsurance
- Implant services
- In-network: 50% coinsurance
- Orthodontics
- Not covered
- Oral/Maxillofacial surgery
- In-network: 50% coinsurance
Vision Services
- 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
Hearing Services
- 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
Additional and Special Needs Services
- Adult day health services
- Not covered
- Home-based palliative care
- Not covered
- Personal emergency response system
- Coming soon
- Weight management programs
- In-network: $0 copay
- Wigs for chemotherapy-related hair loss
- Coming soon
- 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 C-SNP GIVEBACK EXTRAS 025 OH as a Part B benefit.
Prescription Drug Coverage
DEVOTED C-SNP GIVEBACK EXTRAS 025 OH 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.
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: | ($13.30) |
| Supplemental Part D Premium: | $13.30 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | $21.05 |
| 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 C-SNP GIVEBACK EXTRAS 025 OH 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 | Not available |
| Generic | $1.00 copay | Not available |
| Preferred Brand | 25% coinsurance | Not available |
| Non-Preferred Drug | 25% coinsurance | Not available |
| Specialty Tier | 25% coinsurance | Not available |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H2697)
Medicare assigns star ratings to plans based on quality and performance across multiple measures, including customer service, member experience, and health outcomes. Ratings are updated annually by the Centers for Medicare & Medicaid Services (CMS) and are shown on a 1 to 5 star scale, with 5 stars representing the highest quality.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| 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.
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 |
| CMS.gov | Chronic Condition Special Needs Plans (C-SNPs) | April 28, 2026 |
| Medicare.gov | Understanding Medicare Advantage Plans | April 28, 2026 |
| NCOA.org | 5 Steps to Choosing the Right Medicare Plan for You | April 28, 2026 |
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