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Devoted GIVEBACK North Carolina (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted GIVEBACK North Carolina (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted GIVEBACK North Carolina (HMO) in 2025, please refer to our full plan details page.
Devoted GIVEBACK North Carolina (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 4.5 out of 5 stars in 2025.
It's important to know that Devoted GIVEBACK North Carolina (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 North Carolina (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 North Carolina (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 $157.60. 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 $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 North Carolina (HMO) plan has a $590.00 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For Tier 1 (Preferred Generic) drugs, you will pay a $5.00 copay at a standard or mail-order pharmacy. For other tiers, you will pay 25% coinsurance. Once your total yearly drug costs reach $2000.00, you will enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The Devoted GIVEBACK North Carolina (HMO) plan offers comprehensive coverage with a variety of benefits. This plan includes coverage for hospital stays, outpatient services, and emergency care, with varying copays depending on the specific service. You'll also find coverage for primary care visits with no copay, preventive services, and essential services like hearing, vision, and dental, with set copays or coinsurance amounts.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you'll pay a $395 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you'll pay a $395 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered by the Devoted GIVEBACK North Carolina (HMO) plan. Outpatient Hospital Services have a copay between $0 and $495, while Observation Services have a $395 copay. Ambulatory Surgical Center (ASC) Services have no copay, and Outpatient Substance Abuse services have a $45 copay for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted GIVEBACK North Carolina (HMO) plan, but requires prior authorization. You will have a $60 copay for this benefit.
Ambulance and Transportation Services See details
The Devoted GIVEBACK North Carolina (HMO) plan covers ambulance and transportation services, with prior authorization required. Ground ambulance services have a copay between $0 and $295, and air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $125 copay, and Worldwide Emergency Transportation has a 20% coinsurance and a $295 copay, while the other worldwide services have a $125 copay; Urgently Needed Services have a copay between $0 and $55.
Primary Care See details
The Devoted GIVEBACK North Carolina (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $45 copay, and physician specialist services with a $45 copay. Mental health specialty services, psychiatric services, and opioid treatment program services have a $45 copay for individual and group sessions. Physical therapy and speech-language pathology services have a copay between $45 and $50. Additional telehealth benefits have a copay between $0 and $45.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, 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 EKG following Welcome Visit; however, in-home safety assessment, personal emergency response system (PERS), medical nutrition therapy (MNT), post discharge in-home medication reconciliation, re-admission 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 include routine hearing exams with a $40 copay and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a copay between $599 and $899, but inner ear, outer ear, and over the ear prescription hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services with the Devoted GIVEBACK North Carolina (HMO) plan include eye exams with a $40 copay, and eyewear benefits, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Eyewear has a combined maximum benefit of $500 every year.
Dental Services See details
Dental Services include coverage for Medicare dental services with a $45 copay, as well as other dental services with a $500 maximum benefit per year. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay and 20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted GIVEBACK North Carolina (HMO) plan. The coinsurance for Dialysis Services is 20%.
Medical Equipment See details
Medical equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. DME has a 20% coinsurance and requires prior authorization, while Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered; Prosthetic Devices have a 0-20% coinsurance, and Medical Supplies have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, lab services with no copay, and diagnostic procedures/tests with a copay between $0 and $95. Therapeutic Radiological Services have a coinsurance of at most 20%, and Diagnostic Radiological Services have a copay of at most $300. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted GIVEBACK North Carolina (HMO) plan, with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Devoted GIVEBACK North Carolina (HMO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Devoted GIVEBACK North Carolina (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays are not covered.
Other Services See details
The "Devoted GIVEBACK North Carolina (HMO)" plan does not cover acupuncture, over-the-counter (OTC) 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, or Self-Directed Personal Assistance Services. Other Services and Other 2 benefits are covered.
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