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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:
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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 1-month, 2-month, and 3-month supplies at standard pharmacies and standard mail order. Tier 2 generic drugs carry a $10 copay for a 1-month supply at both standard pharmacies and mail order, with savings available on longer fills. For Tier 3 preferred brand drugs and Tier 4 non-preferred drugs, members pay a 25% coinsurance for 1-month, 2-month, or 3-month supplies. Tier 5 specialty drugs also require a 25% coinsurance, which is limited to a 1-month supply at standard pharmacies and standard mail order.
Additional Benefits
The DEVOTED GIVEBACK 051 FL (HMO) plan offers affordable healthcare coverage with no copay and no coinsurance for primary care visits, home health care, and standard preventive services. For specialized medical care, members pay a $45 copay for specialist visits, while inpatient hospital stays require a $395 daily copay for the first 5 to 6 days and no copay for the remaining days. Emergency services are covered with a $130 copay, which is waived if you are admitted, while urgently needed care ranges from no copay to a $50 copay. Supplemental benefits include dental care with no copay for preventive services up to a $1,250 annual limit, and vision coverage featuring no copay for eyewear up to a $350 annual limit. Hearing exams require a $45 copay, and covered prescription hearing aids are available with copays ranging from $599 to $899. Additionally, diagnostic lab services and outpatient X-rays are provided with no copay, while medical equipment and dialysis require no copay but carry coinsurance up to 50% and 20% respectively.
Inpatient Hospital See details
DEVOTED GIVEBACK 051 FL (HMO) covers inpatient hospital services with no coinsurance, requiring a $395 daily copay for days 1 to 6 for acute stays and days 1 to 5 for psychiatric stays, with no copay for remaining days. This benefit is partially covered, as upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED GIVEBACK 051 FL (HMO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital copays range from no copay to $395, observation services carry a $395 copay per stay, and outpatient substance abuse sessions require a $45 copay.
Partial Hospitalization See details
DEVOTED GIVEBACK 051 FL (HMO) covers partial hospitalization benefits with a $55.00 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Ambulance services are covered by DEVOTED GIVEBACK 051 FL (HMO) with prior authorization, featuring no copay to a $320 copay and no coinsurance for ground transport, and a 20% coinsurance with no copay for air transport. Transportation services to health-related locations are not covered.
Emergency Services See details
DEVOTED GIVEBACK 051 FL (HMO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with a copay ranging from no copay to $50 and no coinsurance. Worldwide emergency and urgent care are covered up to a $25,000 maximum limit, requiring a $130 copay and no coinsurance for emergency or urgent services, and a $320 copay plus 20% coinsurance for emergency transportation.
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 therapies are covered with copays ranging from $45 to $65 and no coinsurance, while podiatry services are not covered. Some chiropractic services are covered, but routine and other chiropractic services are not covered.
Preventive Services See details
DEVOTED GIVEBACK 051 FL (HMO) offers preventive services with no copay and no coinsurance for covered benefits like annual physical exams, fitness benefits, and nutritional counseling. However, these services are only partially covered, as sub-services such as in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, and counseling are not covered.
Hearing Services See details
DEVOTED GIVEBACK 051 FL (HMO) offers hearing exam coverage with a $45 copay, no coinsurance, and no deductible. Prescription hearing aids are partially covered with no coinsurance and a copay of $599 to $899 for up to two devices per year, but OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
DEVOTED GIVEBACK 051 FL (HMO) provides partially covered vision services, featuring one routine eye exam per year with a $0 to $45 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $350 annual limit for contacts, eyeglasses, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED GIVEBACK 051 FL (HMO), which offers up to a $1,250 annual limit for dental care with no copay and no coinsurance for preventive services. Medicare-covered dental services require a $45 copay and no coinsurance, while covered comprehensive services have no copay and 0% to 50% coinsurance, though maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by DEVOTED GIVEBACK 051 FL (HMO) with no copay and no coinsurance, although prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs require no copay and a coinsurance of no coinsurance to 20%, while Part B insulin drugs have a $35 copay and a coinsurance of no coinsurance to 20%.
Dialysis Services See details
DEVOTED GIVEBACK 051 FL (HMO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive this covered benefit.
Medical Equipment See details
Medical equipment is covered by DEVOTED GIVEBACK 051 FL (HMO) with no copays, but coinsurance ranges from 0% to 50% and prior authorization is required. This benefit is partially covered as diabetic therapeutic shoes and inserts are not covered under the plan.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 051 FL (HMO) covers diagnostic and radiological services with prior authorization, offering no copay for lab services and outpatient X-rays. Diagnostic tests have no coinsurance and a $0 to $125 copay, while diagnostic radiological services start at a $0 copay and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the DEVOTED GIVEBACK 051 FL (HMO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by DEVOTED GIVEBACK 051 FL (HMO) with no coinsurance, though prior authorization is required. While some services are covered, standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for peripheral artery disease (PAD) are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 051 FL (HMO) covers Skilled Nursing Facility (SNF) care with no coinsurance, requiring prior authorization but allowing admission without a prior three-day hospital stay. There is no copay for days 1 through 20, a daily copay of $218 for days 21 through 100, and additional days beyond the Medicare limit are not covered.
Other Services See details
Other Services under the DEVOTED GIVEBACK 051 FL (HMO) plan are partially covered, offering additional preventive services not covered by Medicare with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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