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Devoted GIVEBACK Pennsylvania (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted GIVEBACK Pennsylvania (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted GIVEBACK Pennsylvania (HMO) in 2025, please refer to our full plan details page.
Devoted GIVEBACK Pennsylvania (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Philadelphia Area. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Devoted GIVEBACK Pennsylvania (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 Pennsylvania (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 Pennsylvania (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 $117.70. 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 $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 Pennsylvania (HMO) plan has a $590 deductible for prescription drugs. After meeting the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For example, you'll pay an $8 copay for preferred generic drugs at a standard or mail-order pharmacy. For standard generic drugs, you'll pay 25% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Devoted GIVEBACK Pennsylvania (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $375 copay for the first few days, with no copay thereafter, while outpatient services may have copays up to $475. The plan includes coverage for primary care, with copays ranging from $0 to $45 depending on the service. Preventive services and home health services have no copay, and vision and dental services are covered with copays and annual maximums. Hearing exams have a $45 copay, and prescription hearing aids are covered with a copay between $599 and $899. Additional benefits include ambulance services and home infusion services.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $375 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you will pay a $375 copay for days 1-4, and no copay for days 5-90.
Outpatient Services See details
Outpatient services, including all outpatient hospital services, are covered. Outpatient hospital services have a copay between $0 and $475, and observation services have a $375 copay. Ambulatory Surgical Center (ASC) Services have no copay, while outpatient substance abuse services have a $45 copay for both individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted GIVEBACK Pennsylvania (HMO) plan, with a $70 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted GIVEBACK Pennsylvania (HMO) plan. Ground Ambulance Services have a copay between $0 and $300, while Air Ambulance Services have a 20% coinsurance; however, Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered under the Devoted GIVEBACK Pennsylvania (HMO) plan, with a $110 copay. Urgently Needed Services are covered with a copay between $0 and $45. Worldwide Emergency Services are covered, including Worldwide Emergency Coverage with a $110 copay, Worldwide Urgent Coverage with a $110 copay, and Worldwide Emergency Transportation with a $300 copay and 20% coinsurance.
Primary Care See details
Primary Care Physician Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Chiropractic Services have a $15 copay for routine care, while Occupational Therapy Services have a copay between $0 and $35, and Physician Specialist Services have a $45 copay. Individual and Group sessions for mental health and psychiatric services have a $45 copay. Physical Therapy and Speech-Language Pathology Services have a copay between $0 and $50, and Additional Telehealth Benefits have a copay between $0 and $45. Opioid Treatment Program Services have a $45 copay. Podiatry Services are not covered.
Preventive Services See details
The Devoted GIVEBACK Pennsylvania (HMO) plan covers preventive services, including annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs, with no copay. However, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers, additional smoking cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, and counseling services are not covered.
Hearing Services See details
Hearing exams are covered with a $45 copay, and routine hearing exams are limited to one per year. Prescription hearing aids are covered with a copay between $599 and $899, and are limited to two per year, while fitting/evaluation for hearing aids is unlimited. However, prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $45 copay, and eyewear with a combined maximum benefit of $250 every year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The Devoted GIVEBACK Pennsylvania (HMO) plan covers Medicare Dental Services with a $45 copay, and other dental services, including oral exams, dental x-rays, and more, with a $250 annual maximum. 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 with a $35 copay and 20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for all services.
Dialysis Services See details
Dialysis Services are covered by the Devoted GIVEBACK Pennsylvania (HMO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment benefits are covered by the Devoted GIVEBACK Pennsylvania (HMO) plan. Durable Medical Equipment has a 20% coinsurance, with no copay, and requires prior authorization. Prosthetic devices have a 0-20% coinsurance, with no copay, while medical supplies have a 20% coinsurance, with no copay. Diabetic Equipment is covered, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests have a minimum copay of $0 and a maximum copay of $95, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $300, and Therapeutic Radiological Services have a maximum coinsurance of 20%, while Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted GIVEBACK Pennsylvania (HMO) plan with no copay and no coinsurance, but prior authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted GIVEBACK Pennsylvania (HMO) plan. While the plan mentions that Cardiac Rehabilitation Services are covered, all listed services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted GIVEBACK Pennsylvania (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 for SNF are not covered.
Other Services See details
Other Services offered by the Devoted GIVEBACK Pennsylvania (HMO) plan 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 benefits are covered, including $0 preventive services.
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