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DEVOTED GIVEBACK 006 OH (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 006 OH (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 OH (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 006 OH (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Western Ohio. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 006 OH (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 OH (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 OH (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 $184.70. 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 $6750.00 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 006 OH (HMO) plan features an annual prescription drug deductible of $605. Under this plan, Tier 1 preferred generic drugs are available with no copay for one-, two-, or three-month supplies through standard pharmacies and standard mail order. Tier 2 generic drugs require a low copay starting at $3.00 for a one-month supply, with three-month mail-order supplies costing just $7.50. Higher-tier medications are subject to coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 22% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs carry a 25% coinsurance. These coinsurance rates apply to both standard retail pharmacies and standard mail-order services.
Additional Benefits
The DEVOTED GIVEBACK 006 OH (HMO) plan offers comprehensive coverage with no copay and no coinsurance for primary care visits, preventive services, and home health care. For inpatient hospital stays, members pay a daily copay of $450 for days one through five, followed by no copay for days six through ninety, all with no coinsurance. Outpatient services, specialist visits, and urgent care are also highly accessible, requiring no coinsurance and low-to-moderate copays. This plan also includes key supplemental benefits, such as dental, vision, and hearing services with no copay for preventive dental care and routine eyewear up to specified annual limits. Diagnostic lab work and outpatient X-rays require no copay or coinsurance, while durable medical equipment has no copay but may include coinsurance up to 50 percent. Some services, including routine transportation, cardiac rehabilitation, and chiropractic care, are not covered under this plan.
Inpatient Hospital See details
DEVOTED GIVEBACK 006 OH (HMO) inpatient hospital services are partially covered, featuring no coinsurance and a copay of $450 per day for days 1 through 5, with no copay for days 6 through 90. Upgrades, non-Medicare-covered stays, and additional days for psychiatric stays are not covered.
Outpatient Services See details
DEVOTED GIVEBACK 006 OH (HMO) covers outpatient services with no coinsurance, though prior authorization is required for most treatments. There is no copay for ambulatory surgical center and outpatient blood services, while outpatient hospital services range from a $0 to $550 copay, observation services require a $450 copay per stay, and outpatient substance abuse sessions cost a $45 copay.
Partial Hospitalization See details
DEVOTED GIVEBACK 006 OH (HMO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance services covered by DEVOTED GIVEBACK 006 OH (HMO) require prior authorization, featuring a copay of $0 to $315 with no coinsurance for ground transport, and a 20% coinsurance with no copay for air transport. Transportation services are not covered under this plan.
Emergency Services See details
DEVOTED GIVEBACK 006 OH (HMO) covers emergency services with a $130 copay (waived if admitted within 24 hours) and no coinsurance, while urgently needed services range from no copay to a $45 copay with no coinsurance. Worldwide emergency services are covered up to a $25,000 lifetime maximum, featuring a $130 copay and no coinsurance for emergency and urgent care, and a $315 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 006 OH (HMO) provides primary care physician services with no copay and no coinsurance, while other covered services like specialist visits, mental health, and physical therapy require copays ranging from $0 to $65 with no coinsurance. Podiatry and chiropractic services are not covered under this plan, and prior authorization is required for most specialist and therapy services.
Preventive Services See details
Preventive Services are covered by DEVOTED GIVEBACK 006 OH (HMO) with no copay and no coinsurance for services like annual physical exams, kidney disease education, and fitness benefits. This benefit is partially covered, meaning some services such as in-home support, personal emergency response systems, and therapeutic massages are not covered.
Hearing Services See details
DEVOTED GIVEBACK 006 OH (HMO) covers annual routine hearing exams with a $45 copay and no coinsurance, as well as unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and copays ranging from no copay to $299 for up to two aids per year, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED GIVEBACK 006 OH (HMO), offering eye exams with a $0 to $45 copay and no coinsurance, though other eye exam services are not covered. Covered eyewear, including contacts, lenses, and frames, has no copay and no coinsurance up to a $400 annual maximum.
Dental Services See details
DEVOTED GIVEBACK 006 OH (HMO) partially covers dental services with a $45 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other covered preventive and comprehensive services up to a $250 yearly maximum. Orthodontics, implant services, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED GIVEBACK 006 OH (HMO) with no copay and no coinsurance, subject to prior authorization and step therapy. Under this benefit, Medicare Part B chemotherapy and other drugs have no copay and no coinsurance to 20% coinsurance, while Part B insulin requires a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
DEVOTED GIVEBACK 006 OH (HMO) covers Dialysis Services with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED GIVEBACK 006 OH (HMO), as diabetic therapeutic shoes and inserts are not covered. Covered items—including durable medical equipment, prosthetics, medical supplies, and diabetic supplies—require no copay, with coinsurance ranging from no coinsurance up to 50% depending on the equipment.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under DEVOTED GIVEBACK 006 OH (HMO) with prior authorization required. Members pay no copay or coinsurance for lab services, outpatient X-rays, and diagnostic radiology, while diagnostic procedures and tests range from a $0 to $150 copay, and therapeutic radiology requires a 20% coinsurance.
Home Health Services See details
DEVOTED GIVEBACK 006 OH (HMO) covers Home Health Services with no copay and no coinsurance. Prior authorization is required to access these covered services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the DEVOTED GIVEBACK 006 OH (HMO) plan, which excludes coverage for cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 006 OH (HMO) covers Skilled Nursing Facility (SNF) care 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, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by DEVOTED GIVEBACK 006 OH (HMO), featuring no copay and no coinsurance for additional preventive services and over-the-counter items up to $130 every three months. Acupuncture and meal benefits are not covered under this plan.
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