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DEVOTED GIVEBACK 049 FL (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 049 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 049 FL (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 049 FL (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Flagler and Volusia Counties. This plan received an overall rating of 5 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 049 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 049 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 049 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 prescription drug coverage for the DEVOTED GIVEBACK 049 FL (HMO) plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs offer no copay for up to a three-month supply at standard pharmacies and standard mail-order services. Tier 2 generic drugs are also highly affordable, with standard copays starting at $5 for a one-month supply. For higher-tier medications, costs transition to coinsurance rather than flat copayments. Tier 3 preferred brand drugs require 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require 25% coinsurance. This structure helps you easily estimate your out-of-pocket medication expenses under this Medicare Advantage plan.
Additional Benefits
The DEVOTED GIVEBACK 049 FL (HMO) plan offers medical coverage with no copay and no coinsurance for primary care visits, preventive services, and home health care. Specialist visits require a $45 copay, while inpatient hospital stays charge a $395 daily copay for the first five to six days with no copay for subsequent days. Outpatient services feature no coinsurance, with copays ranging from no copay for ambulatory surgical centers up to $395 for observation and hospital services. For supplemental care, the plan provides routine vision exams with copays up to $45 and a $350 annual eyewear allowance with no copay. Dental services are covered up to a $1,250 yearly limit with no copay and up to 50% coinsurance, while prescription hearing aids require copays between $599 and $899. Members also receive a $71 over-the-counter allowance every three months, though routine transportation and meal benefits are not covered.
Inpatient Hospital See details
DEVOTED GIVEBACK 049 FL (HMO) covers inpatient hospital services with no coinsurance, requiring a daily copay of $395 for days 1 through 6 for acute stays and days 1 through 5 for psychiatric stays, with no copay for subsequent days. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED GIVEBACK 049 FL (HMO) with no coinsurance for all categories, featuring no copay for ambulatory surgical center and blood services. Patients will pay a $45 copay for outpatient substance abuse sessions, a $395 copay per stay for observation services, and copays ranging from $0 to $395 for outpatient hospital services.
Partial Hospitalization See details
Partial hospitalization is covered by DEVOTED GIVEBACK 049 FL (HMO) with a $60 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by DEVOTED GIVEBACK 049 FL (HMO), which offers ground ambulance services with a copay ranging from no copay to $345 and air ambulance services with a 20% coinsurance. Prior authorization is required for ambulance services, and transportation services to plan-approved or other health-related locations are not covered.
Emergency Services See details
DEVOTED GIVEBACK 049 FL (HMO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if admitted to the hospital within 24 hours. Urgently needed services range from no copay to a $50 copay and no coinsurance, while worldwide emergency services are covered up to $25,000 with a $130 copay and no coinsurance for emergency and urgent care, and a $345 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 049 FL (HMO) offers primary care physician services with no copay and no coinsurance, and specialist visits for a $45 copay and no coinsurance. Additional outpatient therapies and mental health services have copays ranging from $0 to $65 with no coinsurance, though podiatry is not covered, and some chiropractic services are covered but routine and other chiropractic services are not.
Preventive Services See details
Preventive services under the DEVOTED GIVEBACK 049 FL (HMO) plan are covered with no copay and no coinsurance, including annual physical exams, kidney disease education, and select fitness and wellness programs. This benefit is partially covered, as it excludes in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, therapeutic massage, adult day health, palliative care, in-home support, caregiver support, additional smoking cessation sessions, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
Hearing services are partially covered by the DEVOTED GIVEBACK 049 FL (HMO) plan, featuring a $45 copay and no coinsurance for hearing exams. While prescription hearing aids are covered with no coinsurance and a copay of $599 to $899, OTC hearing aids as well as inner ear, outer ear, and over-the-ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED GIVEBACK 049 FL (HMO), as other eye exam services are not covered. Covered benefits include one routine eye exam per year with a $0 to $45 copay and no coinsurance, alongside eyewear up to a $350 annual maximum with no copay or coinsurance.
Dental Services See details
DEVOTED GIVEBACK 049 FL (HMO) partially covers dental services with a $1,250 yearly maximum, excluding maxillofacial prosthetics, implant services, and orthodontics. Medicare-covered dental services require a $45 copay and no coinsurance, while other covered services feature no copay and 0% to 50% coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED GIVEBACK 049 FL (HMO) with no copay, though prior authorization is required. Covered Part B chemotherapy, radiation, and other infusion drugs require a coinsurance ranging from no coinsurance up to 20%, while Part B insulin drugs require a $35 copay and a coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Dialysis Services are covered by DEVOTED GIVEBACK 049 FL (HMO) with no copay and a 20% coinsurance, and prior authorization is required.
Medical Equipment See details
DEVOTED GIVEBACK 049 FL (HMO) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment carries a 20% to 50% coinsurance, prosthetics and medical supplies range from no coinsurance to 20% coinsurance, and diabetic supplies range from no coinsurance to 50% coinsurance, though diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 049 FL (HMO) covers diagnostic services with no coinsurance, featuring no copay for lab services and a copay of $0 to $125 for diagnostic procedures and tests. Covered radiological services require prior authorization and feature no copay for outpatient X-rays, a $0 minimum copay for diagnostic radiological services, and a 20% coinsurance for therapeutic radiological services.
Home Health Services See details
DEVOTED GIVEBACK 049 FL (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED GIVEBACK 049 FL (HMO) offers Cardiac Rehabilitation Services with no copay and no coinsurance, though prior authorization is required. In practice, some services are covered but cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 049 FL (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior three-day hospital stay required. You will pay no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though prior authorization is required and days beyond the standard Medicare-covered limit are not covered.
Other Services See details
DEVOTED GIVEBACK 049 FL (HMO) partially covers other services, offering over-the-counter (OTC) items up to $71 every three months and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and other supplemental services are not covered under this plan.
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