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DEVOTED GIVEBACK 011 PA (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 011 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 011 PA (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 011 PA (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Western Pennsylvania. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED GIVEBACK 011 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 011 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 011 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 $9250.00 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 011 PA (HMO) Medicare plan features an annual prescription drug deductible of $605. Under this plan, Tier 1 preferred generic drugs have no copay for one, two, or three-month fills at standard pharmacies and through standard mail order. Tier 2 generic drugs are also highly affordable, with copays starting at $3 for a one-month supply and ranging up to $9 depending on the supply length and fill method. For brand-name and specialty medications, your costs are determined by coinsurance. Tier 3 preferred brand drugs carry a 21% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance. These cost-sharing percentages apply to both standard pharmacy and standard mail order services, with specialty drugs limited to a one-month supply.
Additional Benefits
The DEVOTED GIVEBACK 011 PA (HMO) plan offers robust medical coverage with predictable cost-sharing, including no copay for primary care visits and a $55 copay for specialist consultations. Inpatient hospital stays require a $425 daily copay for days 1 through 4 and no copay for days 5 through 90, while outpatient services range from no copay up to a $525 copay. Emergency care is accessible with a $115 copay, which is waived if you are admitted to the hospital within 24 hours. This plan also features valuable additional benefits, such as an $82 quarterly allowance for over-the-counter items with no copay and home health services at no copay. Vision and dental benefits are included, offering no copay for eyewear up to a $200 annual limit and no copay for select dental services up to a $250 yearly maximum. Routine preventive services are also covered with no copay or coinsurance, helping you manage your health and budget effectively.
Inpatient Hospital See details
Inpatient hospital services are partially covered by DEVOTED GIVEBACK 011 PA (HMO) with no coinsurance, requiring a $425 daily copay for days 1 through 4 and no copay for days 5 through 90. Non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED GIVEBACK 011 PA (HMO) covers outpatient services with no coinsurance, including ambulatory surgical center and blood services with no copay. Outpatient hospital services require a copay of $0 to $525, observation services require a $425 copay per stay, and outpatient substance abuse sessions have a $50 copay, all with no coinsurance and requiring prior authorization.
Partial Hospitalization See details
DEVOTED GIVEBACK 011 PA (HMO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
DEVOTED GIVEBACK 011 PA (HMO) covers ambulance services with prior authorization, requiring no copay to a $375 copay for ground ambulance services and a 20% coinsurance for air ambulance services. Transportation services are not covered under this plan.
Emergency Services See details
DEVOTED GIVEBACK 011 PA (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 are covered with no coinsurance and a copay ranging from no copay to $40, while worldwide emergency services are covered up to $25,000 with a $115 copay (no coinsurance) for care and a $375 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 011 PA (HMO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $55 copay and no coinsurance. Other covered services like physical therapy, occupational therapy, and mental health services have copays ranging from $35 to $55 with no coinsurance, though podiatry is not covered and chiropractic care is only partially covered since routine and other chiropractic services are excluded.
Preventive Services See details
Preventive services are partially covered by DEVOTED GIVEBACK 011 PA (HMO) with no copay and no coinsurance for covered options like annual physical exams, kidney disease education, and fitness benefits. While many wellness programs are included, several specific sub-services, such as in-home safety assessments, personal emergency response systems, and therapeutic massages, are not covered.
Hearing Services See details
DEVOTED GIVEBACK 011 PA (HMO) hearing services include one routine hearing exam per year for a $55 copay and no coinsurance, alongside unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $599 to $899 for up to two aids yearly, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
DEVOTED GIVEBACK 011 PA (HMO) covers vision services with no coinsurance or deductibles, offering one routine eye exam per year with a copay ranging from no copay to $55, although other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $200 maximum limit per year.
Dental Services See details
DEVOTED GIVEBACK 011 PA (HMO) partially covers dental services, offering Medicare-covered dental for a $55 copay and no coinsurance, and other covered dental services with no copay and no coinsurance up to 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 by DEVOTED GIVEBACK 011 PA (HMO) with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy, radiation, and insulin, require a coinsurance ranging from no coinsurance to 20%, with insulin also requiring a $35 copay.
Dialysis Services See details
DEVOTED GIVEBACK 011 PA (HMO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
DEVOTED GIVEBACK 011 PA (HMO) covers medical equipment with no copays, though coinsurance ranges from 0% to 20% depending on the item and prior authorization is required. Durable medical equipment carries a 17% coinsurance, and diabetic equipment is only partially covered as diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 011 PA (HMO) covers diagnostic and radiological services, offering no coinsurance and a copay ranging from no copay to $95 for diagnostic procedures and tests. Lab services, outpatient X-rays, and diagnostic radiology services have no copay, while therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED GIVEBACK 011 PA (HMO) with no copay and no coinsurance. Prior authorization is required to access these services.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by DEVOTED GIVEBACK 011 PA (HMO) with no coinsurance, though prior authorization is required. Covered services require a copay, which includes $30 for cardiac and intensive cardiac rehabilitation, $25 for pulmonary rehabilitation, and $20 for supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD).
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 011 PA (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. Patients pay no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the standard 100 days are not covered.
Other Services See details
Other services are partially covered by DEVOTED GIVEBACK 011 PA (HMO), with acupuncture and meal benefits not covered. Over-the-counter (OTC) items up to $82 every three months and additional preventive services are covered with no copay and no coinsurance.
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