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DEVOTED GIVEBACK 012 NC (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 012 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 012 NC (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 012 NC (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 5 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 012 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 012 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 012 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 $165.00. 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 $8900.00 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 012 NC (HMO) Medicare prescription drug plan has an annual drug deductible of $605. For Tier 1 preferred generic drugs, members pay no copay for one-month, two-month, or three-month supplies filled at standard pharmacies or through standard mail order. Tier 2 generic drugs are also highly affordable, with standard copays starting at just $3 for a one-month supply. For brand-name and specialty medications, your costs are determined by coinsurance. Tier 3 preferred brand drugs require a 22% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance at standard pharmacies and standard mail order. Note that Tier 5 specialty medications are limited to a one-month supply under this plan.
Additional Benefits
The DEVOTED GIVEBACK 012 NC (HMO) plan offers robust medical coverage with no copay for primary care visits, preventive services, and home health care. For inpatient hospital stays, members pay no coinsurance and a daily copay of $440 for the first four days, followed by no copay for days five through 90. Emergency room visits carry a $115 copay, which is waived if you are admitted, while specialist visits require a $45 copay. This plan also includes key supplemental benefits, such as dental coverage with no copay up to a $500 annual limit and vision services featuring no copay for eyewear up to a $200 yearly maximum. Routine hearing exams require a $45 copay, and prescription hearing aids are covered with copays ranging from $599 to $899. Additionally, skilled nursing facility stays feature no copay for the first 20 days, followed by a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
DEVOTED GIVEBACK 012 NC (HMO) partially covers inpatient hospital services with no coinsurance, requiring a $440 daily copay for days 1 through 4 and no copay for days 5 through 90. Prior authorization is required, and specific services such as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED GIVEBACK 012 NC (HMO) with no coinsurance, featuring copays ranging from $0 to $540 for outpatient hospital services, $440 per stay for observation services, and $45 for substance abuse sessions. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, though prior authorization is required.
Partial Hospitalization See details
DEVOTED GIVEBACK 012 NC (HMO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to receive coverage for these services.
Ambulance and Transportation Services See details
Ambulance services are covered by DEVOTED GIVEBACK 012 NC (HMO) with prior authorization, requiring no copay to a $315 copay for ground ambulance services and a 20% coinsurance for air ambulance services. Transportation services are not covered by this plan, including trips to plan-approved or any health-related locations.
Emergency Services See details
DEVOTED GIVEBACK 012 NC (HMO) covers emergency services with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services range from no copay to a $40 copay with no coinsurance, and worldwide emergency services are covered up to $25,000 with a $115 copay for emergency or urgent care and a $315 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 012 NC (HMO) covers primary care provider visits with no copay and no coinsurance, while specialist visits, psychiatric, and mental health services require a $45 copay and no coinsurance. Physical, occupational, and speech therapy are covered with copays ranging from $35 to $50 and no coinsurance, though podiatry and routine chiropractic care are not covered.
Preventive Services See details
Preventive services are covered by DEVOTED GIVEBACK 012 NC (HMO) with no copay and no coinsurance for annual physicals, kidney disease education, and routine screenings. Additional preventive services are partially covered with no copay and no coinsurance; however, in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, chemotherapy wigs, therapeutic massage, adult day health, palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access technologies, and counseling are not covered.
Hearing Services See details
DEVOTED GIVEBACK 012 NC (HMO) hearing services include one routine hearing exam per year for a $45 copay and no coinsurance, with fitting and evaluation services also covered. Prescription hearing aids are partially covered with a copay ranging from $599 to $899 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
Vision services are partially covered by the DEVOTED GIVEBACK 012 NC (HMO) plan with no deductibles and no coinsurance. Routine eye exams are covered once yearly with a copay ranging from no copay to $45, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $200 annual maximum for contact lenses, frames, lenses, and upgrades.
Dental Services See details
DEVOTED GIVEBACK 012 NC (HMO) dental services are partially covered, excluding maxillofacial prosthetics, implant services, and orthodontics. Covered preventive and comprehensive dental services have no copay and no coinsurance up to a $500 annual maximum, while Medicare-covered dental services require a $45 copay and no coinsurance.
Home Infusion bundled Services See details
DEVOTED GIVEBACK 012 NC (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 drugs require no copay and coinsurance ranging from no coinsurance to 20%, while covered Part B insulin requires a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered by DEVOTED GIVEBACK 012 NC (HMO) with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
DEVOTED GIVEBACK 012 NC (HMO) covers medical equipment with no copay, though prior authorization is required and coinsurance ranges from no coinsurance to 20% depending on the item. This benefit is partially covered, as durable medical equipment, prosthetics, and diabetic supplies are included, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 012 NC (HMO) covers diagnostic and radiological services, requiring prior authorization. Diagnostic procedures have a $0 to $95 copay with no coinsurance, lab and X-ray services have no copay, and therapeutic radiology requires 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED GIVEBACK 012 NC (HMO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED GIVEBACK 012 NC (HMO) with no copay and no coinsurance, but require prior authorization. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by DEVOTED GIVEBACK 012 NC (HMO) with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED GIVEBACK 012 NC (HMO) partially covers other services, offering additional preventive services not covered by Medicare with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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