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Devoted GIVEBACK Ohio (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted GIVEBACK Ohio (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted GIVEBACK Ohio (HMO) in 2025, please refer to our full plan details page.
Devoted GIVEBACK Ohio (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 4.5 out of 5 stars in 2025.
It's important to know that Devoted GIVEBACK Ohio (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 Ohio (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 Ohio (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 $174.70. 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 $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 Ohio (HMO) plan has a $590 deductible for prescription drugs. After meeting your deductible, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, if you use a standard pharmacy, you will pay a $10 copay for preferred generic drugs. You will pay 25% coinsurance for standard generic, preferred brand, and non-preferred drugs. Once your total drug costs reach $2000, you will enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Devoted GIVEBACK Ohio (HMO) plan offers a wide range of benefits, including inpatient and outpatient hospital services, with varying copays. Emergency services have a $125 copay, while primary care and specialist visits have copays of $20-$45. The plan also covers hearing and vision services, with coverage for routine exams and eyewear, and dental services with no copay for oral exams, x-rays, and other diagnostic and preventive services. Additional benefits include coverage for ambulance services, home health services with no copay, and skilled nursing facility services. The plan also covers diagnostic and radiological services, including lab services with no copay. However, some services such as cardiac rehabilitation, additional hours of home health care, and certain dental and vision procedures are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you'll pay a $425 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you'll pay a $425 copay for days 1-4, and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered; Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay between $0 and $550, and observation services, with a $450 copay. Ambulatory Surgical Center (ASC) Services have no copay, and Outpatient Substance Abuse Services have a copay of $45 for both individual and group sessions. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted GIVEBACK Ohio (HMO) plan, and requires prior authorization. The copay for this benefit is $70.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted GIVEBACK Ohio (HMO) plan. Ground ambulance services have a copay of $0 - $350, while air ambulance services have a 20% coinsurance, and transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Devoted GIVEBACK Ohio (HMO) plan with a $125 copay, and no coinsurance. Urgently Needed Services have a copay between $0 and $55, and no coinsurance. Worldwide Emergency Services are covered, including Worldwide Emergency Coverage with a $125 copay, Worldwide Urgent Coverage with a $125 copay, and Worldwide Emergency Transportation with a $350 copay and 20% coinsurance.
Primary Care See details
The Devoted GIVEBACK Ohio (HMO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $45 copay, physician specialist services with a $45 copay, mental health specialty services with a $45 copay, other health care professional services with a copay between $0 and $45, psychiatric services with a $45 copay, physical therapy and speech-language pathology services with a copay between $45 and $65, additional telehealth benefits with a copay between $0 and $45, and opioid treatment program services with a $45 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Devoted GIVEBACK Ohio (HMO) plan covers preventive services including annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. In-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, readmission 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, and counseling services are not covered.
Hearing Services See details
Hearing services are covered, including routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams are covered once per year, and fitting/evaluation for hearing aids has no limit. Prescription hearing aids (all types) are covered with a copay between $0 and $299 for up to 2 visits per year. Prescription hearing aids for the inner, outer, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for routine eye exams once per year, and eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. The plan offers a combined maximum benefit of $300.00 per year for eyewear.
Dental Services See details
The Devoted GIVEBACK Ohio (HMO) plan covers dental services, including oral exams, x-rays, and other diagnostic and preventive services with no copay. Medicare dental services have a $45 copay, and the plan covers orthodontics, restorative services, and other dental procedures. However, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted GIVEBACK Ohio (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits under the Devoted GIVEBACK Ohio (HMO) plan include Durable Medical Equipment (DME) with a 20-25% coinsurance and Prosthetics/Medical Supplies with a coinsurance for Medicare-covered items, but not for Durable Medical Equipment for use outside the home. Diabetic Equipment is covered, but 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/Tests with a copay between $0 and $150, and Lab Services with no copay. Outpatient X-Ray Services have no copay, while Diagnostic Radiological Services have a copay of up to $300. Therapeutic Radiological Services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Devoted GIVEBACK Ohio (HMO) plan with no copay and no coinsurance, but prior authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted GIVEBACK Ohio (HMO) plan. Although some cardiac rehabilitation services are listed as having a copay, the plan does not cover any of them.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Devoted GIVEBACK Ohio (HMO) plan, with a $0 copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include $0 preventive services, while acupuncture, over-the-counter items, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, 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 do not require authorization or a referral.
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