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DEVOTED GIVEBACK 002 NC (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 002 NC (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED GIVEBACK 002 NC (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 002 NC (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in North Carolina Triad. This plan received an overall rating of 5 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 002 NC (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 002 NC (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 002 NC (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 $6700.00 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 002 NC (HMO) plan features an annual drug deductible of $605. Under this plan, you will pay no copay for Tier 1 preferred generic drugs filled at standard pharmacies or through standard mail order. For Tier 2 generic drugs, costs range from a $3 copay for a 1-month supply up to a $9 copay at standard pharmacies or a $7.50 copay for a 3-month supply via standard mail order. For higher-tier medications, your costs are based on coinsurance rather than set copays. Tier 3 preferred brand drugs require a 22% coinsurance, while Tier 4 non-preferred drugs carry a 25% coinsurance. Tier 5 specialty drugs also require a 25% coinsurance for a 1-month supply at standard pharmacies and through standard mail order.
Additional Benefits
The DEVOTED GIVEBACK 002 NC (HMO) plan offers comprehensive medical coverage with no copays or coinsurance for primary care doctor visits, annual physicals, and home health services. For specialized medical needs, specialist visits require a $45 copay, while inpatient hospital stays feature a $395 daily copay for days 1 through 5 and no copay for days 6 through 90. Emergency room care is available with a $130 copay, which is waived upon hospital admission, and urgent care visits range from no copay to $45. This plan also provides valuable dental, vision, and hearing benefits with no deductibles. Preventive and comprehensive dental care features no copay up to a $500 annual maximum, while vision benefits include routine eye exams with a $0 to $45 copay and a $200 annual eyewear allowance. Routine hearing exams require a $45 copay, with prescription hearing aids covered at a copay of $599 to $899.
Inpatient Hospital See details
DEVOTED GIVEBACK 002 NC (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $395 daily copay for days 1 through 5 and no copay for days 6 through 90. Prior authorization is required, and certain services such as upgrades, additional psychiatric days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED GIVEBACK 002 NC (HMO) covers outpatient services with no coinsurance, offering ambulatory surgical center visits and outpatient blood services with no copay. Other covered services require prior authorization, including outpatient hospital services with a copay of $0 to $495, observation services at $395 per stay, and outpatient substance abuse sessions with a $45 copay.
Partial Hospitalization See details
Partial hospitalization is covered by DEVOTED GIVEBACK 002 NC (HMO) with a $60.00 copay and no coinsurance. Prior authorization is required to receive these services.
Ambulance and Transportation Services See details
DEVOTED GIVEBACK 002 NC (HMO) covers ground ambulance services with a copay of $0 to $315 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required. For transportation services, some services are covered, but transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
DEVOTED GIVEBACK 002 NC (HMO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours, and urgently needed services with a copay ranging from no copay to $45 and no coinsurance. Worldwide emergency and urgent care are also covered up to a $25,000 maximum benefit, featuring a $130 copay and no coinsurance, while worldwide emergency transportation has a $315 copay and 20% coinsurance.
Primary Care See details
DEVOTED GIVEBACK 002 NC (HMO) provides primary care physician services with no copay and no coinsurance, while specialist visits require a $45 copay and no coinsurance. Physical, occupational, and speech therapies feature a $45 to $50 copay with no coinsurance, but podiatry and routine chiropractic services are not covered.
Preventive Services See details
DEVOTED GIVEBACK 002 NC (HMO) covers preventive services, including annual physicals, kidney disease education, and fitness benefits, with no copay and no coinsurance. This benefit is partially covered, as sub-services such as in-home safety assessments, personal emergency response systems, medical nutrition therapy, and therapeutic massage are not covered.
Hearing Services See details
Hearing services are partially covered by DEVOTED GIVEBACK 002 NC (HMO), featuring routine exams for a $45 copay and prescription hearing aids with a $599 to $899 copay, with no deductibles or coinsurance. Over-the-counter (OTC) hearing aids and inner ear, outer ear, or over the ear prescription hearing aids are not covered.
Vision Services See details
DEVOTED GIVEBACK 002 NC (HMO) offers partially covered vision services, including one annual routine eye exam with a $0 to $45 copay and no coinsurance, though other eye exam services are not covered. Covered eyewear, including eyeglasses and contact lenses, has no copay or coinsurance and features a $200 annual maximum benefit.
Dental Services See details
DEVOTED GIVEBACK 002 NC (HMO) partially covers dental services, offering preventive and comprehensive care with no copay and no coinsurance up to a $500 annual maximum, though implants, orthodontics, and maxillofacial prosthetics are not covered. Medicare-covered dental services require prior authorization and carry a $45 copay with no coinsurance.
Home Infusion bundled Services See details
DEVOTED GIVEBACK 002 NC (HMO) covers home infusion bundled services with no copay, though prior authorization and step therapy may be required. Associated Medicare Part B drugs, including chemotherapy, radiation, and insulin, carry a coinsurance ranging from 0% to 20%, with insulin drugs also requiring a copay of $35.
Dialysis Services See details
DEVOTED GIVEBACK 002 NC (HMO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
DEVOTED GIVEBACK 002 NC (HMO) covers medical equipment with no copay, although prior authorization is required. Durable medical equipment requires 20% to 50% coinsurance, prosthetics and medical supplies range from no coinsurance to 20% coinsurance, and diabetic equipment is partially covered with up to 50% coinsurance, excluding diabetic therapeutic shoes and inserts which are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED GIVEBACK 002 NC (HMO) with prior authorization required. Diagnostic services feature no coinsurance, with no copay for lab services and a $0 to $95 copay for diagnostic procedures, while radiological services offer outpatient X-rays and diagnostic radiology with no copay and therapeutic radiology with a 20% coinsurance.
Home Health Services See details
Home Health Services are fully covered under the DEVOTED GIVEBACK 002 NC (HMO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED GIVEBACK 002 NC (HMO) with no coinsurance, but some services are covered while cardiac rehabilitation ($40 copay), intensive cardiac rehabilitation ($40 copay), pulmonary rehabilitation ($35 copay), and supervised exercise therapy for peripheral artery disease ($25 copay) are not covered. Prior authorization is required for these rehabilitation services.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 002 NC (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior three-day hospital stay requirement, though prior authorization is required. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, with no coverage provided for additional days beyond the Medicare-covered limit.
Other Services See details
Other services are partially covered by DEVOTED GIVEBACK 002 NC (HMO), featuring no copay and no coinsurance for additional preventive services and over-the-counter items up to $24 every three months. Acupuncture and meal benefits are not covered under this plan.
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