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DEVOTED GIVEBACK 002 MO (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 002 MO (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED GIVEBACK 002 MO (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 002 MO (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in St. Louis/Southeast Missouri. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED GIVEBACK 002 MO (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 002 MO (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 002 MO (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 $164.80. 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 $7000.00 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 002 MO (HMO) Medicare plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs have no copay for 1-month, 2-month, and 3-month supplies at standard pharmacies and standard mail order. For Tier 2 generic drugs, you will pay a low copayment starting at $3 for a 1-month supply, with standard mail order offering a discounted $7.50 copay for a 3-month supply. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 21% coinsurance for standard pharmacy and mail order fills. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance, with specialty coverage limited to 1-month supplies.
Additional Benefits
The DEVOTED GIVEBACK 002 MO (HMO) plan offers robust coverage for essential medical needs, featuring no copay and no coinsurance for primary care visits, home health services, and routine preventive care. For specialist visits, patients pay a $45 copay, while inpatient hospital stays require a $475 daily copay for the first three days and no copay for days four through ninety. Outpatient hospital services range from no copay up to a $575 copay, and emergency room visits carry a $115 copay which is waived if admitted. Ancillary care includes dental and vision benefits with no copay up to specified annual limits, alongside hearing aid coverage with copays ranging from $599 to $899. Diagnostic lab work and outpatient X-rays are available with no copay, while durable medical equipment and dialysis services generally require a twenty percent coinsurance. Skilled nursing facility stays are also covered with no copay for the first twenty days, followed by a daily copay of $218 for days twenty-one through one hundred.
Inpatient Hospital See details
DEVOTED GIVEBACK 002 MO (HMO) partially covers inpatient hospital services with no coinsurance, requiring a $475 daily copay for days 1 through 3 and no copay for days 4 through 90. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED GIVEBACK 002 MO (HMO) offers outpatient services with no coinsurance, featuring a $0 to $575 copay for outpatient hospital services and a $475 copay per stay for observation services. Ambulatory surgical center and outpatient blood services have no copay and no coinsurance, while outpatient substance abuse sessions require a $45 copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by DEVOTED GIVEBACK 002 MO (HMO) with an $80.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
DEVOTED GIVEBACK 002 MO (HMO) covers ground ambulance services with a copay ranging from no copay to $315 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Prior authorization is required for ambulance services, and transportation services are not covered.
Emergency Services See details
DEVOTED GIVEBACK 002 MO (HMO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with no copay to a $40 copay and no coinsurance. Worldwide emergency and urgent care are covered up to $25,000 with a $115 copay and no coinsurance, while worldwide emergency transportation carries a $315 copay and 20% coinsurance.
Primary Care See details
Primary care services through DEVOTED GIVEBACK 002 MO (HMO) feature no copay and no coinsurance for primary care visits, and a $45 copay with no coinsurance for specialists. Therapy and mental health services are covered with copays ranging from $35 to $50 and no coinsurance, while podiatry is not covered, and only some chiropractic services are covered as routine and other chiropractic services are not covered.
Preventive Services See details
DEVOTED GIVEBACK 002 MO (HMO) partially covers preventive services with no copay and no coinsurance for covered care, including annual physical exams, kidney disease education, and fitness benefits. Several supplemental services are not covered, including personal emergency response systems (PERS), therapeutic massage, medical nutrition therapy, and in-home support.
Hearing Services See details
Hearing Services are partially covered by DEVOTED GIVEBACK 002 MO (HMO) with no deductible, featuring routine exams for a $45 copay and no coinsurance, and up to two prescription hearing aids per year for a $599 to $899 copay and no coinsurance. Over-the-counter (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 002 MO (HMO) partially covers vision services, offering eye exams 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 $200 annual maximum for contact lenses, eyeglasses, and upgrades.
Dental Services See details
DEVOTED GIVEBACK 002 MO (HMO) partially covers dental services, offering Medicare-covered dental care for a $45 copay and no coinsurance, and preventive and comprehensive dental services with no copay and no coinsurance up to a $250 annual maximum. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED GIVEBACK 002 MO (HMO) with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs have no copay and 0% to 20% coinsurance, while Part B insulin carries a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
DEVOTED GIVEBACK 002 MO (HMO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required for this covered benefit.
Medical Equipment See details
Medical equipment is covered by DEVOTED GIVEBACK 002 MO (HMO) with no copays, though prior authorization is required and coinsurance ranges from no coinsurance up to 20%. Durable medical equipment has a 20% coinsurance, and diabetic equipment is partially covered as diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 002 MO (HMO) covers diagnostic services with no coinsurance, offering lab services at no copay and diagnostic procedures with copays ranging from $0 to $95. Covered radiological services require prior authorization and feature no copay for outpatient X-rays, diagnostic radiological services starting at a $0 copay, and therapeutic radiological services with a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED GIVEBACK 002 MO (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED GIVEBACK 002 MO (HMO) covers Cardiac Rehabilitation Services with no coinsurance, though prior authorization is required. While some services are covered, specific sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are not covered by the plan.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 002 MO (HMO) covers skilled nursing facility (SNF) services with no coinsurance, requiring prior authorization and no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though additional days beyond the standard Medicare benefit are not covered.
Other Services See details
Other services are partially covered by DEVOTED GIVEBACK 002 MO (HMO), offering additional preventive services with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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