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DEVOTED GIVEBACK 004 OR (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 004 OR (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED GIVEBACK 004 OR (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 004 OR (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Oregon. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 004 OR (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 004 OR (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 004 OR (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 $154.20. 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 $7900.00 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 004 OR (HMO) Medicare plan features an annual prescription drug deductible of $605. Under this plan, you will pay no copay for Tier 1 preferred generic drugs through standard pharmacies and standard mail order. For Tier 2 generic drugs, costs remain low with a $3.00 copay for a 1-month supply at standard pharmacies and mail order. For higher-tier medications, costs are based on coinsurance rather than flat copays. 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 standard pharmacy and mail-order services.
Additional Benefits
The DEVOTED GIVEBACK 004 OR (HMO) plan offers comprehensive medical coverage with predictable out-of-pocket costs, featuring no copays for primary care visits, preventive care, home health services, and standard laboratory tests. For specialized care, members pay a $50 copay for specialist visits and a $385 daily copay for the first five days of inpatient hospital stays, after which there is no copay. Emergency room visits require a $115 copay, which is waived if you are admitted, while urgent care services range from no copay to a $40 copay. This plan also includes essential supplemental benefits to help manage your routine health costs. Preventive and comprehensive dental services, as well as routine eyewear, are available with no copay up to annual limits of $250 and $200 respectively. Routine eye exams carry a low copay of up to $20, while hearing exams require a $50 copay, and durable medical equipment is covered with a 15% coinsurance.
Inpatient Hospital See details
DEVOTED GIVEBACK 004 OR (HMO) covers inpatient hospital services with no coinsurance, requiring a $385 daily copay for days 1 through 5 and no copay for days 6 through 90. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric hospital days are not covered.
Outpatient Services See details
Outpatient services under DEVOTED GIVEBACK 004 OR (HMO) are covered with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient substance abuse sessions require a $50 copay, while outpatient hospital services carry a copay of $0 to $525 and observation services require a $385 copay per stay.
Partial Hospitalization See details
DEVOTED GIVEBACK 004 OR (HMO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by DEVOTED GIVEBACK 004 OR (HMO), with ground ambulance services requiring no copay to a $345 copay (and no coinsurance) and air ambulance services requiring a 20% coinsurance (and no copay). Prior authorization is required for all ambulance services, and while transportation is technically covered, services to plan-approved or any other health-related locations are not covered in practice.
Emergency Services See details
DEVOTED GIVEBACK 004 OR (HMO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with a copay ranging from no copay to $40 and no coinsurance. Worldwide emergency services are also covered up to a $25,000 maximum, with a $115 copay and no coinsurance for emergency and urgent care, and a $345 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 004 OR (HMO) offers primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, and mental health services require a $50 copay and no coinsurance. Occupational therapy is available with a $35 copay and no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are covered by DEVOTED GIVEBACK 004 OR (HMO) with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management training. Additional preventive benefits are partially covered with no copay and no coinsurance, excluding in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, adult day health, home-based palliative care, in-home support, caregiver support, smoking cessation counseling, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
DEVOTED GIVEBACK 004 OR (HMO) covers hearing exams with a $50 copay and no coinsurance, including one routine annual exam and unlimited fitting evaluations. Prescription hearing aids are partially covered with a $599 to $899 copay and no coinsurance for up to two aids per year, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
DEVOTED GIVEBACK 004 OR (HMO) offers partially covered vision services, as other eye exam services are not covered. Routine eye exams are covered with a $0 to $20 copay, no coinsurance, and no deductible, while eyewear is covered with no copay, no coinsurance, and no deductible up to a $200 yearly limit.
Dental Services See details
Dental services are partially covered by DEVOTED GIVEBACK 004 OR (HMO), with most preventive and comprehensive care options requiring no copay and no coinsurance up to a $250 yearly maximum. Medicare-covered dental services require a $50 copay and no coinsurance, while implant services, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED GIVEBACK 004 OR (HMO) covers Home Infusion bundled Services with no copay, though prior authorization and step therapy are required. Covered Medicare Part B chemotherapy, radiation, and other Part B drugs have no copay and range from no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and ranges from no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the DEVOTED GIVEBACK 004 OR (HMO) plan with no copay and a 20% coinsurance, and prior authorization is required.
Medical Equipment See details
DEVOTED GIVEBACK 004 OR (HMO) covers medical equipment with no copays, though coinsurance and prior authorization apply. Durable medical equipment has a 15% coinsurance, prosthetics and medical supplies carry no coinsurance to 15% coinsurance, and diabetic equipment is partially covered with no coinsurance to 15% coinsurance, as diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 004 OR (HMO) covers diagnostic and radiological services, with prior authorization required for both. Lab services, outpatient X-rays, and diagnostic radiological services have no copay and no coinsurance, while diagnostic tests have a copay of $0 to $95 with no coinsurance, and therapeutic radiological services require 20% coinsurance.
Home Health Services See details
DEVOTED GIVEBACK 004 OR (HMO) covers Home Health Services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by DEVOTED GIVEBACK 004 OR (HMO) with no coinsurance and require prior authorization. While some services are covered, cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) rehabilitation services are not covered in practice.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 004 OR (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. You will pay no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, while additional days beyond the Medicare limit are not covered.
Other Services See details
Other Services are partially covered by DEVOTED GIVEBACK 004 OR (HMO), which offers acupuncture and additional preventive services with no copay and no coinsurance. Over-the-counter (OTC) items, meal benefits, and other miscellaneous services are not covered under this plan.
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