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DEVOTED GIVEBACK 009 PA (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 009 PA (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED GIVEBACK 009 PA (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 009 PA (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Eastern Pennsylvania. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED GIVEBACK 009 PA (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 009 PA (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 009 PA (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 $7000.00 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 009 PA (HMO) Medicare plan features an annual drug deductible of $605. Under this plan, you will have no copay for Tier 1 preferred generic drugs filled at standard pharmacies or through standard mail order. Tier 2 generic medications are also highly affordable, starting at a $3 copay for a 1-month supply at standard pharmacies and standard mail order. For higher-tier medications, costs are structured as coinsurance rather than flat copays. You will pay 21% coinsurance for Tier 3 preferred brand drugs and 25% coinsurance for Tier 4 non-preferred drugs through standard channels. Specialty medications in Tier 5 are covered with a 25% coinsurance for a 1-month supply.
Additional Benefits
The DEVOTED GIVEBACK 009 PA (HMO) plan features robust coverage with no copay for primary care visits, preventive services, home health care, and laboratory tests. For specialized or intensive care, members will encounter predictable copays, such as $55 for specialist visits, $115 for emergency room services, and a $475 daily copay for the first few days of inpatient hospital stays. Outpatient hospital services are also covered with no coinsurance and copays ranging from no copay up to $575. This plan also includes key supplemental benefits, including eyewear covered up to a $200 annual limit with no copay and no coinsurance. Dental and hearing services are partially covered, featuring no copay for general dental up to $250 annually and prescription hearing aids starting at a $599 copay. Additionally, members receive an $87 over-the-counter allowance every three months with no copay and enjoy skilled nursing facility stays with no copay for the first 20 days.
Inpatient Hospital See details
DEVOTED GIVEBACK 009 PA (HMO) covers inpatient hospital services with no coinsurance, requiring a $475 daily copay for days 1 through 3 for acute stays and days 1 through 4 for psychiatric stays, with no copay for remaining days. Prior authorization is required, and upgrades or non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered under the DEVOTED GIVEBACK 009 PA (HMO) plan with no coinsurance, including no copay for ambulatory surgical center and blood services. Patients will pay a $50 copay for outpatient substance abuse sessions, $475 per stay for observation services, and between $0 to $575 for outpatient hospital services, with prior authorization required.
Partial Hospitalization See details
Partial hospitalization is covered by DEVOTED GIVEBACK 009 PA (HMO) with a $70.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by DEVOTED GIVEBACK 009 PA (HMO) with prior authorization, requiring no copay to a $315 copay plus coinsurance for ground transport, and a 20% coinsurance plus a copay for air transport. Transportation services to health-related locations are not covered.
Emergency Services See details
DEVOTED GIVEBACK 009 PA (HMO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services have no copay to a $40 copay and no coinsurance, while worldwide emergency services are covered up to a $25,000 lifetime maximum with copays up to $315 and 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 009 PA (HMO) provides primary care physician services with no copay and no coinsurance, while specialist visits require a $55 copay and no coinsurance. Additional covered services, including physical, occupational, and mental health therapies, feature copays ranging from $35 to $55 and no coinsurance, whereas chiropractic and podiatry services are not covered.
Preventive Services See details
DEVOTED GIVEBACK 009 PA (HMO) covers preventive services with no copay and no coinsurance, including annual physical exams, kidney disease education, fitness programs, and nutrition counseling. While several supplemental benefits are included, this benefit is partially covered as services such as in-home safety assessments, personal emergency response systems, and therapeutic massages are not covered.
Hearing Services See details
Hearing services are covered by DEVOTED GIVEBACK 009 PA (HMO), featuring routine hearing exams for a $55 copay and no coinsurance, and unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a copay between $599 and $899 for up to two aids per year, while OTC hearing aids and inner ear, outer ear, or over the ear prescription aids are not covered.
Vision Services See details
DEVOTED GIVEBACK 009 PA (HMO) offers partially covered vision services, including one routine eye exam per year with a $0 to $55 copay, no coinsurance, and prior authorization required, while other eye exam services are not covered. Eyewear, including contacts, eyeglasses, and upgrades, is covered with no copay and no coinsurance up to a $200 annual maximum benefit.
Dental Services See details
DEVOTED GIVEBACK 009 PA (HMO) offers partially covered dental services, including Medicare-covered dental for a $55 copay and no coinsurance, and other dental services with no copay and no coinsurance up to a $250 annual maximum. While many preventive and restorative services are covered, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED GIVEBACK 009 PA (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs feature no copay and coinsurance ranging from no coinsurance to 20%, while Part B insulin drugs require a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
DEVOTED GIVEBACK 009 PA (HMO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED GIVEBACK 009 PA (HMO) covers medical equipment with no copays, though prior authorization is required. Durable Medical Equipment (DME) features a 17% coinsurance, while prosthetics and medical supplies have no coinsurance to 20% coinsurance. Diabetic equipment is partially covered, offering no coinsurance to 17% coinsurance for diabetic supplies, but diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 009 PA (HMO) covers diagnostic and radiological services under prior authorization, with no coinsurance and a $0 to $95 copay for diagnostic procedures and tests. Lab services, outpatient X-rays, and diagnostic radiological services feature no copay and no coinsurance, while therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
DEVOTED GIVEBACK 009 PA (HMO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED GIVEBACK 009 PA (HMO) covers some Cardiac Rehabilitation Services with no coinsurance and required prior authorization, though several sub-services are not covered in practice. Specifically, standard cardiac rehabilitation ($30 copay), intensive cardiac rehabilitation ($30 copay), pulmonary rehabilitation ($25 copay), and supervised exercise therapy for peripheral artery disease ($20 copay) are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 009 PA (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by DEVOTED GIVEBACK 009 PA (HMO) with no copay and no coinsurance for additional preventive services and over-the-counter (OTC) items, which include an $87 allowance every three months. Acupuncture, meal benefits, and other sub-services are not covered under this plan.
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