A non-government entity
Devoted GIVEBACK Missouri (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted GIVEBACK Missouri (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted GIVEBACK Missouri (HMO) in 2025, please refer to our full plan details page.
Devoted GIVEBACK Missouri (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Greater St. Louis. The overall rating for this plan is not yet available for 2025.
It's important to know that Devoted GIVEBACK Missouri (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 Missouri (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 Missouri (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 $147.70. 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 $590.00 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:
Sign up for Devoted GIVEBACK Missouri (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 Missouri (HMO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590.00. In the initial coverage phase, after the deductible is met, you'll pay a $10 copay for preferred generic drugs at standard and mail-order pharmacies. Standard generic drugs, preferred brand drugs, and non-preferred drugs have a 25% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Devoted GIVEBACK Missouri (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $475 copay for the first 3 days, and then no copay for days 4-90. Outpatient services have copays ranging from $0 to $575, and emergency services have a $110 copay. Preventive services are covered with no copay, while primary care visits have copays from $15 to $45. The plan also includes coverage for hearing, vision, and dental services, with specific copays and annual maximums. Home health services have no copay, and skilled nursing facility services have no copay for the first 20 days, then a $214 copay for days 21-100.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For the first 3 days, there is a $475 copay, and days 4-90 have no copay. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered Stay for Inpatient Hospital-Acute and Upgrades for Inpatient Hospital-Acute are not covered. Additional days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $575, observation services have a $475 copay, ambulatory surgical center services have no copay, and both individual and group outpatient substance abuse sessions have a $45 copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted GIVEBACK Missouri (HMO) plan, with a copay of $80.00. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Devoted GIVEBACK Missouri (HMO), with prior authorization required for all ambulance services. Ground ambulance services have a copay of $0 - $300, while air ambulance services have a 20% coinsurance, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Devoted GIVEBACK Missouri (HMO) plan. Emergency Services have a $110 copay, while Urgently Needed Services have a copay between $0 and $45. Worldwide Emergency Transportation has a 20% coinsurance and a $300 copay, while Worldwide Emergency Coverage and Worldwide Urgent Coverage both have a $110 copay.
Primary Care See details
The Devoted GIVEBACK Missouri (HMO) plan covers primary care physician services, chiropractic services, occupational therapy, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $15 copay, occupational therapy has a $35 copay, physician specialist services have a $45 copay, mental health specialty services, psychiatric services, and opioid treatment program services have a $45 copay, physical therapy and speech-language pathology services have a $45-$50 copay, and other health care professional services have a $0-$45 copay. Routine chiropractic care is not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, kidney disease education, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit. In-Home Safety Assessments, Personal Emergency Response Systems (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Therapeutic Massage, Adult Day Health Services, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies, and Counseling Services are not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $45 copay and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $599 and $899, while inner ear, outer ear, and over-the-ear prescription hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
The Devoted GIVEBACK Missouri (HMO) plan covers vision services, including routine eye exams with a $45 copay, eyewear with a combined maximum benefit of $250 per year, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
Dental services are covered, with a $250 annual maximum. Medicare dental services require prior authorization and have a $45 copay. Other dental services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 20% coinsurance, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the Devoted GIVEBACK Missouri (HMO) plan. The coinsurance for Dialysis Services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 17% coinsurance and authorization required, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a coinsurance between 0% and 20%, and Medical Supplies have a 20% coinsurance; both require authorization. Diabetic Equipment is covered, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Devoted GIVEBACK Missouri (HMO) plan. Diagnostic Procedures/Tests have a copay between $0 and $95, and Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $300, Therapeutic Radiological Services have 20% coinsurance, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted GIVEBACK Missouri (HMO) plan with no copay and no coinsurance, but prior authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Devoted GIVEBACK Missouri (HMO), but the plan does not cover any specific sub-services. The plan does not specify a copay or coinsurance for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted GIVEBACK Missouri (HMO) plan. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered for SNF, and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services are not covered by the Devoted GIVEBACK Missouri (HMO) plan, including acupuncture, over-the-counter items, meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing, case management, institution for mental disease services, services in an intermediate care facility, tobacco cessation counseling, freestanding birth center services, respiratory care services, family planning services, nursing home services, home and community based services, personal care services, and self-directed personal assistance services.
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