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DEVOTED GIVEBACK 013 PA (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 013 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 013 PA (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 013 PA (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Central Pennsylvania. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED GIVEBACK 013 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 013 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 013 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 013 PA (HMO) Medicare plan features an annual prescription drug deductible of $605. Under this plan, Tier 1 preferred generic drugs are covered with no copay for one-month, two-month, or three-month supplies filled through standard pharmacies and standard mail order. For Tier 2 generic medications, you will pay a low copay of $3.00 for a one-month supply, up to a maximum of $9.00 for a three-month standard retail supply or $7.50 for a three-month standard mail-order supply. Higher-tier medications under this plan require coinsurance instead of flat copays during the initial coverage phase. Tier 3 preferred brand drugs require a 21% coinsurance for all supply durations at standard pharmacies and mail-order services. Tier 4 non-preferred drugs and Tier 5 specialty tier drugs both carry a 25% coinsurance for standard pharmacy and standard mail-order fills.
Additional Benefits
The DEVOTED GIVEBACK 013 PA (HMO) plan offers comprehensive coverage for core healthcare needs, featuring no copay for primary care visits, home health care, and annual physicals. Specialist visits require a $55 copay, while inpatient hospital stays carry a $475 daily copay for the first few days and no copay for subsequent days. Emergency room visits have a $115 copay, which is waived if you are admitted within 24 hours. This plan also provides valuable supplemental benefits, including dental care with no copay up to a $250 annual limit and vision coverage with a $200 yearly eyewear allowance. Hearing services are covered with a $55 copay for routine exams, and members receive an $83 over-the-counter allowance every three months. Most covered services under this plan require no coinsurance, helping to keep your out-of-pocket costs predictable.
Inpatient Hospital See details
DEVOTED GIVEBACK 013 PA (HMO) covers inpatient hospital services with no coinsurance, requiring a $475 daily copay for days 1 to 3 of acute stays and days 1 to 4 of psychiatric stays, and no copay for subsequent days. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED GIVEBACK 013 PA (HMO) with no coinsurance across all categories, though prior authorization is required for these benefits. While ambulatory surgical center and blood services have no copay, outpatient hospital services require a $0 to $525 copay, observation services have a $475 copay per stay, and outpatient substance abuse sessions carry a $50 copay.
Partial Hospitalization See details
Partial hospitalization is covered under the DEVOTED GIVEBACK 013 PA (HMO) plan with a $70.00 copay and no coinsurance. Prior authorization is required to receive these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by DEVOTED GIVEBACK 013 PA (HMO), with ground ambulance services requiring coinsurance and a copay ranging from no copay to $315, and air ambulance services requiring a 20% coinsurance and a copay. Prior authorization is required for all ambulance services, and while some transportation services are covered, transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
DEVOTED GIVEBACK 013 PA (HMO) covers emergency services with a $115 copay and no coinsurance, waived if admitted within 24 hours, and urgently needed services with no copay to a $40 copay and no coinsurance. Worldwide emergency and urgent services are covered up to a $25,000 limit with a $115 copay and no coinsurance, while worldwide emergency transportation requires a $315 copay and 20% coinsurance.
Primary Care See details
DEVOTED GIVEBACK 013 PA (HMO) provides primary care physician services with no copay and no coinsurance, while specialist visits require a $55 copay and no coinsurance. Other covered benefits like physical and occupational therapy, psychiatric care, and telehealth have copays ranging from $0 to $55 with no coinsurance, though chiropractic and podiatry services are not covered.
Preventive Services See details
DEVOTED GIVEBACK 013 PA (HMO) partially covers preventive services with no copay and no coinsurance for covered benefits such as annual physical exams, fitness programs, and home safety devices. Services not covered under this plan include in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, chemotherapy wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access, and counseling.
Hearing Services See details
DEVOTED GIVEBACK 013 PA (HMO) covers hearing services with no deductible, including annual routine hearing exams for a $55 copay and no coinsurance, requiring prior authorization. Prescription hearing aids are partially covered with no coinsurance and copays between $599 and $899, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
DEVOTED GIVEBACK 013 PA (HMO) offers partially covered vision services, including one annual routine eye exam with a $0 to $20 copay, no coinsurance, and no deductible, though other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, up to a $200 yearly maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED GIVEBACK 013 PA (HMO) partially covers dental services, offering preventive and comprehensive care with no copay and no coinsurance up to a $250 annual limit, though maxillofacial prosthetics, implant services, and orthodontics are not covered. Medicare-covered dental services are available with a $55 copay and no coinsurance.
Home Infusion bundled Services See details
DEVOTED GIVEBACK 013 PA (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, insulin, and other drugs carry a coinsurance ranging from no coinsurance up to 20%, with insulin drugs also requiring a $35 copay.
Dialysis Services See details
DEVOTED GIVEBACK 013 PA (HMO) covers Dialysis Services with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
DEVOTED GIVEBACK 013 PA (HMO) partially covers medical equipment with no copay, though prior authorization is required and diabetic therapeutic shoes and inserts are not covered. Durable medical equipment requires a 15% coinsurance, while covered diabetic supplies carry up to 15% coinsurance and prosthetics or medical supplies range from no coinsurance up to 20% coinsurance.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 013 PA (HMO) covers diagnostic and radiological services with prior authorization required. Diagnostic lab services have no copay and no coinsurance, diagnostic procedures have a copay of $0 to $95 with no coinsurance, and radiological services range from no copay for outpatient X-rays to a copay and minimum 20% coinsurance for therapeutic treatments.
Home Health Services See details
Home Health Services are covered by the DEVOTED GIVEBACK 013 PA (HMO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are partially covered by DEVOTED GIVEBACK 013 PA (HMO) with no coinsurance and required prior authorization, though copayments may apply. Standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered under this plan.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 013 PA (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, no prior three-day inpatient hospital stay is needed for admission, and additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
DEVOTED GIVEBACK 013 PA (HMO) partially covers other services, offering over-the-counter (OTC) items up to $83 every three months and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and other supplemental services are not covered under this plan.
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