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DEVOTED GIVEBACK 031 FL (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 031 FL (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED GIVEBACK 031 FL (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 031 FL (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Clay, Duval, Nassau, and St. Johns Counties. This plan received an overall rating of 5 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 031 FL (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about DEVOTED GIVEBACK 031 FL (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For DEVOTED GIVEBACK 031 FL (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $184.70. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $605.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6750.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The DEVOTED GIVEBACK 031 FL (HMO) Medicare plan features an annual prescription drug deductible of $605. Under this plan, Tier 1 preferred generic drugs have no copay for standard pharmacy and standard mail-order fills. For Tier 2 generic drugs, you will pay a low copay starting at $5 for a 1-month supply, up to a maximum of $15 for a 3-month standard pharmacy supply. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance for standard pharmacy and mail-order services. This structured prescription drug coverage helps you easily manage and project your healthcare budget.
Additional Benefits
The DEVOTED GIVEBACK 031 FL (HMO) plan offers affordable coverage with no copay and no coinsurance for primary care doctor visits and routine preventive services. For inpatient hospital stays, there is no coinsurance, but members pay a $395 copay for the first 5 to 6 days and no copay for any additional days. Emergency room visits require a $130 copay, which is waived upon admission, while outpatient hospital services range from no copay to a $395 copay. Specialist visits and mental health services feature copays ranging from $0 to $65, and home health services are provided with no copay. Additionally, the plan features a $1,250 annual dental benefit with no copay for preventive care, a $350 yearly allowance for eyewear, and a $116 quarterly allowance for over-the-counter health products. Routine hearing and vision exams are also covered with low copays, helping you manage your out-of-pocket healthcare costs.
Inpatient Hospital See details
DEVOTED GIVEBACK 031 FL (HMO) partially covers inpatient hospital services with no coinsurance, requiring a $395 copay for days 1 to 6 of acute stays and days 1 to 5 of psychiatric stays, followed by no copay for subsequent days. Upgrades, psychiatric additional days, and non-Medicare-covered stays are not covered under this plan.
Outpatient Services See details
DEVOTED GIVEBACK 031 FL (HMO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $395, observation services cost a $395 copay per stay, and outpatient substance abuse sessions have a $45 copay.
Partial Hospitalization See details
Partial hospitalization is covered by DEVOTED GIVEBACK 031 FL (HMO) with a $55.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Ambulance services are covered by DEVOTED GIVEBACK 031 FL (HMO) with prior authorization, featuring a ground ambulance copay of $0 to $350 along with coinsurance, and an air ambulance coinsurance of 20% along with a copayment. Transportation services to health-related locations are not covered.
Emergency Services See details
DEVOTED GIVEBACK 031 FL (HMO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services are covered with no coinsurance and a copay ranging from no copay to $50, while worldwide emergency services are covered up to $25,000 with a $130 copay for emergency or urgent care and a $350 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 031 FL (HMO) primary care benefits are partially covered, offering no copay and no coinsurance for primary care physician visits, though chiropractic and podiatry services are not covered. Covered specialist visits, mental health services, and physical therapies require copays ranging from $0 to $65 and no coinsurance.
Preventive Services See details
DEVOTED GIVEBACK 031 FL (HMO) covers preventive services with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management. While additional benefits like fitness programs and nutritional counseling are covered, other services such as in-home safety assessments, personal emergency response systems, and therapeutic massages are not covered.
Hearing Services See details
Hearing services are partially covered by DEVOTED GIVEBACK 031 FL (HMO), which features one routine hearing exam per year for a $45 copay and no coinsurance, and up to two prescription hearing aids per year with a copay ranging from $599 to $899 and no coinsurance. OTC hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
DEVOTED GIVEBACK 031 FL (HMO) offers partially covered vision services, featuring one routine eye exam per year with a $0 to $45 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a combined maximum plan benefit of $350 per year for contacts, eyeglasses, and upgrades.
Dental Services See details
DEVOTED GIVEBACK 031 FL (HMO) dental services are partially covered up to a $1,250 annual maximum, with Medicare-covered dental requiring a $45 copay and no coinsurance. Preventive care, periodontics, and oral surgery have no copay and no coinsurance, while restorative, endodontics, and prosthodontics have no copay and 0% to 50% coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED GIVEBACK 031 FL (HMO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
DEVOTED GIVEBACK 031 FL (HMO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
DEVOTED GIVEBACK 031 FL (HMO) partially covers medical equipment with no copays, though prior authorization is required. Durable medical equipment carries a 20% to 50% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance up to 20% or 50% coinsurance; however, diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the DEVOTED GIVEBACK 031 FL (HMO) plan, with prior authorization required. There is no copay for lab services and outpatient X-rays, diagnostic procedures have no coinsurance and a copay ranging from $0 to $125, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home health services are covered under DEVOTED GIVEBACK 031 FL (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered under the DEVOTED GIVEBACK 031 FL (HMO) plan with no coinsurance, but some services are not covered in practice. Standard cardiac rehabilitation ($40 copay), intensive cardiac rehabilitation ($40 copay), pulmonary rehabilitation ($35 copay), and supervised exercise therapy for peripheral artery disease ($25 copay) are not covered and require prior authorization.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 031 FL (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no preceding three-day inpatient hospital stay. There is no copay for days 1 through 20 and a $218 copay for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services covered by DEVOTED GIVEBACK 031 FL (HMO) include additional preventive services and over-the-counter (OTC) items with no copay and no coinsurance, featuring a $116 allowance every three months for OTC products. Acupuncture and meal benefits are not covered under this plan.
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