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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 Southwest Missouri. 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:
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Drug Coverage
The Devoted GIVEBACK Missouri (HMO) plan has a $590 deductible for prescription drugs. After you meet your deductible, you will pay a copay or coinsurance for your prescriptions. During the initial coverage phase, you'll pay a $9 copay for preferred generic drugs at standard and mail order pharmacies. For standard generic, preferred brand, and non-preferred drugs, you pay 25% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for your covered drugs.
Additional Benefits
The Devoted GIVEBACK Missouri (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, but there is no copay for days 4-90. The plan covers outpatient services, including some with no copay, and covers emergency, hearing, vision, and dental services, each with its own copay or coinsurance structure. Other key benefits include coverage for home health services with no copay, and skilled nursing facility stays with no copay for the first 20 days. The plan also provides coverage for ambulance services, diagnostic services, and medical equipment, with different copays and coinsurance amounts depending on the service.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care. For acute care, you will pay a $475 copay for days 1-3, and no copay for days 4-90. Psychiatric care also has a $475 copay for days 1-3, and no copay for days 4-90. Additional days for inpatient hospital acute are covered, but non-Medicare covered stays and upgrades for inpatient hospital acute are not covered. Additional days and non-Medicare covered stays for inpatient hospital psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services with a copay between $0 and $575, observation services with a $475 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with a $45 copay for both individual and group sessions. Outpatient blood services are also covered, and this plan waives the three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted GIVEBACK Missouri (HMO) plan, and requires prior authorization. You will pay an $80 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted GIVEBACK Missouri (HMO) plan. Ground ambulance services have a copay of $0-$300, and air ambulance services have a 20% coinsurance, while 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 under the Devoted GIVEBACK Missouri (HMO) plan. Emergency Services has a $110 copay, and Worldwide Emergency Coverage has a $110 copay with 20% coinsurance for Worldwide Emergency Transportation, while Urgently Needed Services has a copay between $0 and $45.
Primary Care See details
The Devoted GIVEBACK Missouri (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $15 copay, occupational therapy services have a $35 copay, physician specialist services have a $45 copay, individual and group mental health and psychiatric sessions have a $45 copay, physical therapy and speech-language pathology services have a $45 to $50 copay, additional telehealth benefits have a $0 to $45 copay, and opioid treatment program services have a $45 copay. Routine chiropractic care is not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with no copay, annual physical exams, and additional preventive services like health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit. In-Home Safety Assessment, Personal Emergency Response System (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 (including Web/Phone-based technologies and Nursing Hotline), and Counseling Services are not covered.
Hearing Services See details
Hearing exams are covered with a $45 copay, with coverage including routine hearing exams and fitting/evaluation for hearing aids. Prescription hearing aids are covered with a copay between $599 and $899 for all types of prescription hearing aids, but not for inner ear, outer ear, or over the ear hearing aids. OTC hearing aids are not covered.
Vision Services See details
The Devoted GIVEBACK Missouri (HMO) plan covers vision services, including eye exams with a $45 copay, and eyewear with a combined maximum benefit of $250 every year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental services include coverage for Medicare dental services with a $45 copay, and other dental services with a $250 maximum benefit per year. Some other services covered 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, requiring prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay with a 20% coinsurance. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted GIVEBACK Missouri (HMO) plan. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with an 18% coinsurance and no copay, though DME for use outside the home is not covered. Prosthetic Devices have a coinsurance between 0% and 20% and no copay, while Medical Supplies have a 15% coinsurance and no copay. Diabetic Equipment is covered, though Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures and tests with a copay ranging from $0 to $95, lab services with no copay, and outpatient X-ray services with no copay. Diagnostic Radiological Services have a copay of at most $300, and Therapeutic Radiological Services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Devoted GIVEBACK Missouri (HMO) plan with no copay and no coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services. The copay information is available below, but the exact amount is not provided.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted GIVEBACK Missouri (HMO) plan. There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered, and non-Medicare-covered stays are not covered.
Other Services See details
Other Services, including acupuncture, over-the-counter items, meal benefits, dual eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing services, case management, institution for mental disease services, services in an intermediate care facility, case management, 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, are not covered. Other services are covered, including preventive services.
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