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DEVOTED GIVEBACK 009 OH (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 009 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 009 OH (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 009 OH (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Central Ohio. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 009 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 009 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 009 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 009 OH (HMO) prescription drug plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs are fully covered with no copay for 1-month, 2-month, and 3-month supplies at standard pharmacies and through standard mail order. For Tier 2 generic drugs, you will pay a low copay starting at $3.00 for a 1-month supply, with standard mail order options offering a 3-month supply for a $7.50 copay. Brand-name and specialty medications on this plan are subject to coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 22% coinsurance, while Tier 4 non-preferred drugs carry a 25% coinsurance for both standard pharmacy and mail order fills. Tier 5 specialty drugs also require a 25% coinsurance and are limited to a 1-month supply.
Additional Benefits
The DEVOTED GIVEBACK 009 OH (HMO) plan offers comprehensive medical coverage featuring no copays for primary care visits, routine preventive services, and home health care. Specialist office visits require a $45 copay, while inpatient hospital stays carry a $450 daily copay for the first five days followed by no copay for days 6 through 90. Emergency room visits have a $130 copay, which is waived if you are admitted to the hospital within 24 hours. This plan also includes valuable supplemental benefits to help lower your out-of-pocket healthcare costs. Preventive and comprehensive dental services are covered with no copay up to a $250 annual maximum, and routine eye exams are available with no copay to a $45 copay alongside a $200 yearly eyewear allowance. Additionally, members receive a $140 allowance every three months for over-the-counter items with no copay, making it easier to manage everyday health needs.
Inpatient Hospital See details
DEVOTED GIVEBACK 009 OH (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a daily copay of $450 for days 1 through 5 and no copay for days 6 through 90. Prior authorization is required, and the benefit is partially covered since upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services covered by DEVOTED GIVEBACK 009 OH (HMO) feature no coinsurance, with copays ranging from $0 to $550 for outpatient hospital services and $450 per stay for observation services. Ambulatory surgical center and outpatient blood services have no copay or coinsurance, while outpatient substance abuse individual and group sessions carry a $45 copay.
Partial Hospitalization See details
Partial hospitalization is covered by the DEVOTED GIVEBACK 009 OH (HMO) plan with a $70.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Ambulance services are covered by DEVOTED GIVEBACK 009 OH (HMO) with prior authorization, requiring a $0 to $350 copay for ground transport and a 20% coinsurance with no copay for air transport. Transportation services are not covered in practice, as trips to plan-approved or health-related locations are excluded.
Emergency Services See details
Emergency services are covered by DEVOTED GIVEBACK 009 OH (HMO) with a $130 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours. Urgently needed services require no copay to a $45 copay with no coinsurance, while worldwide emergency services are covered up to $25,000 with a $130 copay for emergency or urgent care and a $350 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 009 OH (HMO) covers primary care provider visits with no copay and no coinsurance, while specialist visits require a $45 copay and no coinsurance. Additional benefits like therapy, mental health, and telehealth services have copays ranging from $0 to $65 with no coinsurance, while podiatry and chiropractic services are not covered.
Preventive Services See details
DEVOTED GIVEBACK 009 OH (HMO) covers preventive services, including annual physical exams, kidney disease education, and other screenings, with no copay and no coinsurance. Additional preventive services are partially covered with no copay and no coinsurance, but do not cover in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, chemotherapy wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED GIVEBACK 009 OH (HMO), featuring a $45 copay and no coinsurance for one annual routine hearing exam, as well as unlimited fitting evaluations. Up to two prescription hearing aids are covered per year with no coinsurance and a copay of $599 to $899, though over-the-counter (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 009 OH (HMO), offering one annual routine eye exam with no deductible, a copay ranging from no copay to $45, and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no deductible, no copay, and no coinsurance up to a $200 yearly maximum for contacts, lenses, frames, and upgrades.
Dental Services See details
DEVOTED GIVEBACK 009 OH (HMO) provides partially covered dental services with no copay and no coinsurance for preventive and comprehensive care up to a $250 annual maximum, though maxillofacial prosthetics, implant services, and orthodontics are not covered. Medicare-covered dental services are also available under the plan with a $45 copay and no coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED GIVEBACK 009 OH (HMO) with no copay and no coinsurance, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs have no copay and 0% to 20% coinsurance, while Part B insulin requires a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by DEVOTED GIVEBACK 009 OH (HMO) with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED GIVEBACK 009 OH (HMO) partially covers medical equipment with no copays and prior authorization requirements, though diabetic therapeutic shoes and inserts are not covered. Covered durable medical equipment requires 20% to 50% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance to 20% or 50% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED GIVEBACK 009 OH (HMO) with no coinsurance and a $0 to $150 copay for diagnostic tests, while lab services have no copay. Radiological services feature no copay for outpatient X-rays, a minimum $0 copay for diagnostic radiological services, and a minimum 20% coinsurance for therapeutic radiological services.
Home Health Services See details
DEVOTED GIVEBACK 009 OH (HMO) covers Home Health Services with no copay and no coinsurance. Prior authorization is required to receive these covered services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED GIVEBACK 009 OH (HMO) with no coinsurance and require prior authorization. While some services are covered, specific sub-services like cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) are not covered in practice.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 009 OH (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, though prior authorization is required and additional days beyond the Medicare-covered limit are not covered. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, with no prior three-day hospital stay required for admission.
Other Services See details
Other Services under DEVOTED GIVEBACK 009 OH (HMO) are partially covered, as acupuncture and meal benefits are not covered. Covered benefits include additional preventive services and over-the-counter items up to $140 every three months, both offered with no copay and no coinsurance.
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