A non-government entity
DEVOTED GIVEBACK 051 FL (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 051 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 051 FL (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 051 FL (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Greater Tampa Bay. This plan received an overall rating of 5 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 051 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 051 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 051 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 $615.00 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:
Sign up for DEVOTED GIVEBACK 051 FL (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The DEVOTED GIVEBACK 051 FL (HMO) prescription drug plan features an annual drug deductible of $615. Under this plan, Tier 1 preferred generic drugs are available with no copay for up to a 3-month supply at standard pharmacies and through standard mail order. For Tier 2 generic medications, you will pay a $10 copay for a 1-month supply, which scales up to $30 at standard pharmacies or a discounted $25 for a 3-month supply via standard mail order. For higher-tier medications, costs are based on a percentage of the drug cost rather than flat copays. Tier 3 preferred brand drugs, Tier 4 non-preferred drugs, and Tier 5 specialty drugs all require a 25% coinsurance through standard pharmacies and standard mail order. This 25% coinsurance applies to 1-month, 2-month, and 3-month supplies for Tiers 3 and 4, and to 1-month supplies for Tier 5 specialty drugs.
Additional Benefits
The DEVOTED GIVEBACK 051 FL (HMO) plan offers primary care visits, annual physicals, lab services, and home health care with no copay and no coinsurance. Specialist visits and routine eye exams require a copay of up to $45, while emergency room visits carry a $130 copay. For inpatient hospital stays, you will pay a $395 daily copay for the first several days and no copay for the remaining days of your stay. Preventive dental care has no copay up to a $1,250 annual limit, and prescription eyewear is covered with no copay up to a $350 annual maximum. Routine hearing exams require a $45 copay, and covered hearing aids carry a copay between $599 and $899. Skilled nursing facility stays feature no copay for the first 20 days, followed by a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
DEVOTED GIVEBACK 051 FL (HMO) covers inpatient hospital services with no coinsurance, requiring a $395 daily copay for days 1 through 6 for acute stays and days 1 through 5 for psychiatric stays, with no copay for remaining days. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED GIVEBACK 051 FL (HMO) covers outpatient services with no coinsurance, featuring a $0 to $395 copay for outpatient hospital services and a $395 copay per stay for observation services. Ambulatory surgical center and blood services are covered with no copay, while outpatient substance abuse sessions require a $45 copay with no coinsurance.
Partial Hospitalization See details
Partial hospitalization benefits are covered by DEVOTED GIVEBACK 051 FL (HMO) with a $55.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
DEVOTED GIVEBACK 051 FL (HMO) covers ambulance services with prior authorization, offering ground ambulance services with a copay ranging from no copay up to $325 plus coinsurance, and air ambulance services with a 20% coinsurance plus a copay. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency services are covered by DEVOTED GIVEBACK 051 FL (HMO) with a $130 copay (waived if admitted within 24 hours) and no coinsurance, while urgently needed services require no copay to a $50 copay and no coinsurance. Worldwide emergency and urgent care are covered up to $25,000 with a $130 copay and no coinsurance, and worldwide emergency transportation has a $325 copay and 20% coinsurance.
Primary Care See details
DEVOTED GIVEBACK 051 FL (HMO) offers primary care physician services with no copay and no coinsurance, and specialist visits with a $45 copay and no coinsurance. Physical, occupational, and speech therapy services range from a $45 to $65 copay with no coinsurance, while podiatry and chiropractic services are not covered.
Preventive Services See details
DEVOTED GIVEBACK 051 FL (HMO) provides preventive services, including annual physical exams and kidney disease education, with no copay and no coinsurance. Additional preventive benefits are partially covered with no copay and no coinsurance, excluding services like in-home safety assessments, personal emergency response systems, and medical nutrition therapy.
Hearing Services See details
DEVOTED GIVEBACK 051 FL (HMO) hearing services are partially covered, featuring one annual routine hearing exam for a $45 copay and no coinsurance, plus unlimited fitting evaluations. Up to two prescription hearing aids are covered per year with no coinsurance and a copay between $599 and $899, but inner ear, outer ear, over the ear, and over-the-counter hearing aids are not covered.
Vision Services See details
DEVOTED GIVEBACK 051 FL (HMO) partially covers vision services, as other eye exam services are not covered. Routine eye exams are covered with a $0 to $45 copay and no coinsurance, while eyewear has an annual maximum benefit of $350 with no copay and no coinsurance.
Dental Services See details
DEVOTED GIVEBACK 051 FL (HMO) dental services are covered with a $45 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for preventive care up to a $1,250 annual maximum. Comprehensive dental benefits are partially covered with no copay and 0% to 50% coinsurance, though orthodontics, implant services, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by DEVOTED GIVEBACK 051 FL (HMO) with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy, require 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 051 FL (HMO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED GIVEBACK 051 FL (HMO) partially covers medical equipment with no copay, though prior authorization is required. Covered items like durable medical equipment, prosthetics, and diabetic supplies carry coinsurance ranging from no coinsurance up to 50%, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED GIVEBACK 051 FL (HMO) with prior authorization required. Lab services and outpatient X-rays have no copay, diagnostic procedures and tests have a copay ranging from $0 to $125 with no coinsurance, and therapeutic radiological services carry a 20% coinsurance.
Home Health Services See details
DEVOTED GIVEBACK 051 FL (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services under DEVOTED GIVEBACK 051 FL (HMO) require prior authorization and feature no coinsurance, though only some services are covered. Standard cardiac rehabilitation ($40 copay), intensive cardiac rehabilitation ($40 copay), pulmonary rehabilitation ($35 copay), and SET for PAD services ($25 copay) are not covered by this plan.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 051 FL (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered under the DEVOTED GIVEBACK 051 FL (HMO) plan, featuring no copay and no coinsurance for additional preventive services not covered by Medicare. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered under this plan.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved