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DEVOTED GIVEBACK 006 MO (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 006 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 006 MO (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 006 MO (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Southwest/South Central Missouri. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED GIVEBACK 006 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 006 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 006 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 $164.70. 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 $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 prescription drug coverage for the DEVOTED GIVEBACK 006 MO (HMO) plan features an annual drug deductible of $605. Under this plan, you will pay no copay for Tier 1 preferred generic drugs filled at standard pharmacies or through standard mail order. Tier 2 generic drugs are also highly affordable, costing a low $3.00 copay for a 1-month supply at standard retail pharmacies or standard mail order. For brand-name and specialty medications, you will pay a coinsurance rate instead of a flat copayment. Tier 3 preferred brand drugs require a 21% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs carry a 25% coinsurance for both standard pharmacy and standard mail order options.
Additional Benefits
The DEVOTED GIVEBACK 006 MO (HMO) plan offers robust coverage for essential medical services with predictable out-of-pocket costs. Members enjoy no copay and no coinsurance for primary care visits, home health services, and preventive care, while specialist visits require a $45 copay. Inpatient hospital stays require a $475 copay for the first three days, after which there is no copay, and emergency room visits feature a $115 copay that is waived if you are admitted. For supplemental benefits, the plan provides routine eye exams with copays ranging from no copay up to $45, along with a $200 annual eyewear allowance featuring no copay. Dental care includes preventive services with no copay up to a $250 annual maximum, while hearing aids are covered with copays between $599 and $899. Diagnostic services like lab tests and outpatient X-rays are available with no copay, while durable medical equipment and dialysis services require no copay but carry up to a 20% coinsurance.
Inpatient Hospital See details
Inpatient hospital services are partially covered by DEVOTED GIVEBACK 006 MO (HMO) with no coinsurance, requiring a $475 copay for days 1 through 3 and no copay for days 4 through 90 per stay. While unlimited additional acute days are covered, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services under DEVOTED GIVEBACK 006 MO (HMO) are covered with no coinsurance, featuring no copays for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay ranging from no copay to $575, observation services cost a $475 copay per stay, and outpatient substance abuse sessions carry a $45 copay, with prior authorization required.
Partial Hospitalization See details
DEVOTED GIVEBACK 006 MO (HMO) covers partial hospitalization services with an $80.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
DEVOTED GIVEBACK 006 MO (HMO) covers ambulance services with prior authorization, offering ground ambulance services with a copay ranging from no copay to $315 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 006 MO (HMO) with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no coinsurance and a copay ranging from no copay to $40, while worldwide emergency services are covered up to $25,000 with a $115 copay (no coinsurance) for emergency or urgent care and a $315 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 006 MO (HMO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $45 copay and no coinsurance. Other benefits like mental health, telehealth, and physical therapy feature copays ranging from $0 to $50 and no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by DEVOTED GIVEBACK 006 MO (HMO) with no copay and no coinsurance. Covered benefits include annual physicals, fitness programs, and nutritional training, while sub-services such as in-home support, therapeutic massage, and personal emergency response systems are not covered.
Hearing Services See details
Hearing services are partially covered by the DEVOTED GIVEBACK 006 MO (HMO) plan, offering routine hearing exams for a $45 copay and no coinsurance, and prescription hearing aids with a $599 to $899 copay and no coinsurance. However, OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision Services are partially covered under the DEVOTED GIVEBACK 006 MO (HMO) plan, which features a $0 to $45 copay and no coinsurance for one routine eye exam per year, while other eye exam services are not covered. Eyewear is also covered with no copay, no coinsurance, and no deductible up to a $200 annual maximum.
Dental Services See details
DEVOTED GIVEBACK 006 MO (HMO) offers partially covered dental services, including Medicare-covered dental care for a $45 copay and no coinsurance, plus other preventive and comprehensive services with no copay and no coinsurance up to a $250 annual maximum. While many restorative, endodontic, and surgical treatments are covered, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED GIVEBACK 006 MO (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Covered Medicare Part B drugs, such as chemotherapy and radiation, have no copay and a coinsurance ranging from no coinsurance to 20%, while Part B insulin drugs have a $35 copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
DEVOTED GIVEBACK 006 MO (HMO) covers dialysis services with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
DEVOTED GIVEBACK 006 MO (HMO) partially covers medical equipment, as diabetic therapeutic shoes and inserts are not covered. Covered durable medical equipment, prosthetics, and diabetic supplies require prior authorization and have no copay, with coinsurance ranging from no coinsurance to 20% depending on the item.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 006 MO (HMO) covers diagnostic and radiological services with prior authorization, offering diagnostic services with no coinsurance, no copay for lab services, and a $0 to $95 copay for diagnostic tests. For radiological services, members pay no copay for outpatient X-rays, a $0 minimum copay for diagnostic radiological services, and a 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Home Health Services are covered under the DEVOTED GIVEBACK 006 MO (HMO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the DEVOTED GIVEBACK 006 MO (HMO) plan with no copay, no coinsurance, and required prior authorization. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 006 MO (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but not requiring a 3-day prior hospital stay. You will pay no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by the DEVOTED GIVEBACK 006 MO (HMO) plan, which features 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 under this plan.
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