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DEVOTED GIVEBACK 035 FL (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 035 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 035 FL (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 035 FL (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Lake, Marion, and Sumter Counties. This plan received an overall rating of 5 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 035 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 035 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 035 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 035 FL (HMO) Medicare plan features an annual drug deductible of $605. Under this plan, you will pay no copay for Tier 1 preferred generic drugs filled at standard pharmacies or through standard mail order. For Tier 2 generic drugs, standard copays start at $5.00 for a one-month supply, with standard mail order offering three-month supplies for $12.50. For higher-tier medications, cost-sharing transitions to coinsurance. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs carry a 25% coinsurance for standard pharmacy and mail order fills. Tier 5 specialty drugs also have a 25% coinsurance, which is limited to a one-month supply.
Additional Benefits
The DEVOTED GIVEBACK 035 FL (HMO) plan offers affordable essential healthcare coverage, featuring no copay and no coinsurance for primary care visits, home health services, and annual preventive physicals. Specialist visits require a $45 copay, while inpatient hospital stays require a $395 daily copay for the first 5 to 6 days and no copay thereafter. Emergency room visits carry a $130 copay, which is waived if you are admitted, while urgently needed care ranges from no copay to a $50 copay. For dental and vision care, members receive a $1,250 annual dental limit with no copay for preventive services, alongside a $350 yearly eyewear allowance and routine eye exams with copays up to $45. Hearing coverage includes routine exams for a $45 copay and up to two prescription hearing aids per year with copays ranging from $599 to $899. Diagnostic lab tests and outpatient X-rays are available with no copay or low copays, while durable medical equipment is covered with no copay and 20% to 50% coinsurance.
Inpatient Hospital See details
Inpatient hospital services are covered by DEVOTED GIVEBACK 035 FL (HMO) with no coinsurance, but require prior authorization. For acute care, there is a $395 daily copay for days 1 through 6 and no copay for days 7 and beyond, while psychiatric care requires a $395 daily copay for days 1 through 5 and no copay for days 6 through 90. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED GIVEBACK 035 FL (HMO) covers outpatient hospital services with no coinsurance and a copay of $0 to $395, and observation services with no coinsurance and a $395 copay per stay. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse services require a $45 copay and no coinsurance.
Partial Hospitalization See details
DEVOTED GIVEBACK 035 FL (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization is required for this covered benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by DEVOTED GIVEBACK 035 FL (HMO), though transportation to plan-approved or any health-related locations is not covered. Covered ground ambulance services require a copay of $0 to $350 and no coinsurance, while air ambulance services require a 20% coinsurance and no copay, with prior authorization required.
Emergency Services See details
DEVOTED GIVEBACK 035 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 require no copay to a $50 copay and no coinsurance, while worldwide emergency services are covered up to $25,000 with copays up to $350 and 20% coinsurance for transportation.
Primary Care See details
DEVOTED GIVEBACK 035 FL (HMO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $45 copay and no coinsurance. Other services like physical therapy, mental health, and telehealth have copays ranging from $0 to $65 and no coinsurance, though podiatry and chiropractic services are not covered.
Preventive Services See details
DEVOTED GIVEBACK 035 FL (HMO) covers preventive services, including annual physical exams and kidney disease education, with no copay and no coinsurance. Additional preventive benefits are partially covered, excluding in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs for chemotherapy hair loss, therapeutic massage, adult day health services, home-based palliative care, in-home support services, caregiver support, additional smoking cessation counseling, enhanced disease management, telemonitoring, remote access technologies, and counseling services.
Hearing Services See details
Hearing services are covered under the DEVOTED GIVEBACK 035 FL (HMO) plan, including one routine exam per year for a $45 copay and no coinsurance, subject to prior authorization. Up to two prescription hearing aids are covered annually with no coinsurance and a copay ranging from $599 to $899, though OTC, inner ear, outer ear, and over-the-ear models are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED GIVEBACK 035 FL (HMO), featuring one annual routine eye exam with a $0 to $45 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay or coinsurance up to a $350 yearly maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED GIVEBACK 035 FL (HMO) offers partially covered dental services up to a $1,250 annual maximum, featuring no copay and no coinsurance for preventive care, and no copay with 0% to 50% coinsurance for restorative, endodontic, and prosthodontic services. Medicare-covered dental services require a $45 copay and no coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED GIVEBACK 035 FL (HMO) with no copay, though prior authorization is required and Part D home infusion drugs are not included in the bundle. Associated Medicare Part B chemotherapy, radiation, and other drugs have no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED GIVEBACK 035 FL (HMO) plan with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
DEVOTED GIVEBACK 035 FL (HMO) partially covers medical equipment with no copays, featuring coinsurance of 20% to 50% for durable medical equipment, no coinsurance to 20% coinsurance for prosthetics and medical supplies, and no coinsurance to 50% coinsurance for diabetic supplies. Prior authorization is required for these services, and diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 035 FL (HMO) covers diagnostic and radiological services with prior authorization, featuring no coinsurance and a copay ranging from no copay to $125 for diagnostic tests and labs. Outpatient X-rays and diagnostic radiological services have no copay, while therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED GIVEBACK 035 FL (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services under DEVOTED GIVEBACK 035 FL (HMO) require prior authorization and feature no coinsurance, but only some services are covered. Standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered under this plan and require copayments ranging from $25 to $40.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by DEVOTED GIVEBACK 035 FL (HMO) with no coinsurance and do not require a prior three-day inpatient hospital stay, though prior authorization is required. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered under DEVOTED GIVEBACK 035 FL (HMO), offering over-the-counter items and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and other supplemental services are not covered.
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