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DEVOTED GIVEBACK 010 MO (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 010 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 010 MO (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 010 MO (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Southern Missouri. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED GIVEBACK 010 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 010 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 010 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 $159.90. 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 010 MO (HMO) prescription drug plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs have no copay for 1-month, 2-month, or 3-month supplies at standard pharmacies and standard mail order. Tier 2 generic drugs are also highly affordable, requiring a low $3.00 copay for a 1-month supply at standard retail pharmacies and standard mail order. For higher-tier medications, cost sharing is based on coinsurance percentages rather than flat copays. Tier 3 preferred brand drugs require a 21% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance for standard pharmacy and mail-order fills. These clear tiers help beneficiaries estimate their annual out-of-pocket prescription drug expenses.
Additional Benefits
The DEVOTED GIVEBACK 010 MO (HMO) plan offers robust coverage for essential medical services, featuring no copay for primary care visits, preventive services, and home health care. Specialist visits require a $55 copay, while inpatient hospital stays incur a $475 daily copay for the first three days followed by no copay for days 4 through 90. Emergency room visits have a $115 copay, which is waived if you are admitted, and urgent care options range from no copay up to a $40 copay. For supplemental care, the plan provides dental and vision benefits, including no copay for preventive dental up to a $250 annual limit and no copay for eyewear up to a $200 annual maximum. Routine hearing exams require a $55 copay, and prescription hearing aids are covered with copays ranging from $599 to $899. Additionally, skilled nursing facility stays feature no copay for the first 20 days, though some services like transportation and over-the-counter items are not covered by this plan.
Inpatient Hospital See details
DEVOTED GIVEBACK 010 MO (HMO) 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. This benefit is partially covered as unlimited additional days are included for acute care, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED GIVEBACK 010 MO (HMO) covers outpatient services with no coinsurance, featuring a $475 copay per stay for observation services and a copay ranging from no copay up to $575 for outpatient hospital services. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions require a $50 copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by DEVOTED GIVEBACK 010 MO (HMO) with an $80 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services under the DEVOTED GIVEBACK 010 MO (HMO) plan cover 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, while transportation services to health-related locations are not covered.
Emergency Services See details
DEVOTED GIVEBACK 010 MO (HMO) covers emergency services with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no copay to a $40 copay and no coinsurance, while worldwide emergency services are covered up to $25,000 with copays up to $315 and 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 010 MO (HMO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $55 copay and no coinsurance. Physical, occupational, mental health, and psychiatric therapies require copays ranging from $35 to $55 with no coinsurance, while podiatry is not covered. Some chiropractic services are covered with a $15 copay and no coinsurance, but routine care and other chiropractic services are not covered.
Preventive Services See details
DEVOTED GIVEBACK 010 MO (HMO) covers preventive services with no copay and no coinsurance, including annual physical exams, fitness benefits, and kidney disease education. These additional preventive benefits are partially covered, as the plan excludes services such as in-home support, therapeutic massage, personal emergency response systems (PERS), and caregiver support.
Hearing Services See details
DEVOTED GIVEBACK 010 MO (HMO) partially covers hearing services, offering one routine hearing exam per year with a $55 copay and no coinsurance. Up to two prescription hearing aids are covered annually with no coinsurance and a copay between $599 and $899, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
DEVOTED GIVEBACK 010 MO (HMO) vision services are partially covered, offering one routine eye exam per year with a $0 to $55 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $200 annual maximum for contacts, lenses, frames, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED GIVEBACK 010 MO (HMO), with Medicare-covered dental services requiring a $55 copay and no coinsurance. Other covered preventive and comprehensive services have no copay and no coinsurance up to a $250 annual maximum, though maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED GIVEBACK 010 MO (HMO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Associated Medicare Part B chemotherapy, radiation, and other drugs have no copay and a coinsurance ranging from no coinsurance to 20%, while covered Part B insulin requires a $35 copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis services are covered by DEVOTED GIVEBACK 010 MO (HMO) with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
DEVOTED GIVEBACK 010 MO (HMO) partially covers medical equipment with no copays, though prior authorization is required. Durable medical equipment carries an 18% coinsurance, while prosthetics, medical supplies, and diabetic supplies have coinsurance ranging from no coinsurance up to 20%; however, diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 010 MO (HMO) covers diagnostic and radiological services with prior authorization required. Diagnostic tests and labs feature no coinsurance, with lab services having no copay and tests carrying a $0 to $95 copay. Diagnostic radiological services have a copay starting at $0, therapeutic radiological services require a 20% coinsurance, and outpatient X-rays have no copay but may incur coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED GIVEBACK 010 MO (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED GIVEBACK 010 MO (HMO) with no coinsurance and prior authorization required, though only some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered. These non-covered services require copayments ranging from $20 to $30.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 010 MO (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a 3-day prior hospital stay is not required for admission, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by DEVOTED GIVEBACK 010 MO (HMO), 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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