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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 Charlotte. 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 $147.70. 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 $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 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For Tier 1 and Tier 2 drugs, you will pay either a $5 copay or 25% coinsurance at standard pharmacies. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Devoted GIVEBACK North Carolina (HMO) plan offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays. Emergency, primary care, hearing, vision, and dental services are also included, with specific copays and annual maximums for certain services like eyewear and dental. The plan also provides coverage for home health and skilled nursing facilities, with some limitations on coverage for additional services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered by the Devoted GIVEBACK North Carolina (HMO) plan. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you will pay a $440 copay for days 1-4, and no copay for days 5-90. Additional days for Inpatient Hospital Psychiatric and Non-Medicare-covered Stay for Inpatient Hospital-Acute are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $540, Observation Services with a $440 copay, Ambulatory Surgical Center (ASC) Services with no copay, Individual and Group Sessions for Outpatient Substance Abuse with a copay of $45, and Outpatient Blood Services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted GIVEBACK North Carolina (HMO) plan. The plan has a $70 copay for this benefit, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted GIVEBACK North Carolina (HMO) plan, with prior authorization required for all ambulance services. 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 Urgently Needed Services have a copay between $0 and $55. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 copay, while Worldwide Emergency Transportation has a $295 copay and 20% coinsurance.
Primary Care See details
The Devoted GIVEBACK North Carolina (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 $50, 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
Preventive Services include coverage for Medicare-covered preventive 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 screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit. 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 (including Web/Phone-based technologies and Nursing Hotline), and Counseling Services are not covered.
Hearing Services See details
Hearing exams are covered with a $45 copay, as are routine hearing exams and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a copay between $599 and $899, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, nor are OTC hearing aids.
Vision Services See details
The Devoted GIVEBACK North Carolina (HMO) plan covers vision services including eye exams with a $45 copay, and eyewear with a combined maximum benefit of $500 every year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $45 copay, and other dental services with a $500 maximum benefit per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered. Orthodontic Services are covered under Diagnostic and Preventive Dental. Maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. 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 between 0% and 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 benefits include Durable Medical Equipment (DME) with 15% coinsurance and no copay, Prosthetic Devices with 0-20% coinsurance and no copay, and Medical Supplies with 20% coinsurance and no copay; however, Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services with a copay, and lab services with no copay. Diagnostic Procedures/Tests have a copay between $0 and $95, while Diagnostic Radiological Services have a maximum copay of $300. Therapeutic Radiological Services have a coinsurance of at least 20%, and 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, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the specific services of Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD are not covered. The plan has a copay for some Cardiac and Pulmonary Rehabilitation Services, but the specific copay amount is not provided.
Skilled Nursing Facility (SNF) See details
The Devoted GIVEBACK North Carolina (HMO) plan covers Skilled Nursing Facility (SNF) services with prior authorization required. For days 1-20, there is no copay, and for days 21-100, the copay is $214 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services are not covered, including 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. Other 2 services include $0 preventive services.
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