A non-government entity
DEVOTED GIVEBACK 015 PA (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 015 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 015 PA (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 015 PA (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Western Pennsylvania Area. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED GIVEBACK 015 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 015 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 015 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:
Sign up for DEVOTED GIVEBACK 015 PA (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The DEVOTED GIVEBACK 015 PA (HMO) medicare plan features an annual drug deductible of $605. You will pay no copay for Tier 1 preferred generic drugs filled through standard pharmacies or standard mail order. For Tier 2 generic medications, standard pharmacy copays start at $3 for a one-month supply, while standard mail order offers a three-month supply for a $7.50 copay. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 21% coinsurance for both standard retail and mail-order fills of any duration. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance, with specialty medications limited to a one-month supply.
Additional Benefits
The DEVOTED GIVEBACK 015 PA (HMO) plan offers robust medical coverage with no copay for primary care visits and a $55 copay for specialist visits, both featuring no coinsurance. Inpatient hospital stays require a $425 daily copay for days 1 through 4 followed by no copay for days 5 through 90, while emergency room visits carry a $115 copay that is waived if admitted. Outpatient services feature no coinsurance, with copays ranging from no copay for ambulatory surgical centers up to $525 for outpatient hospital care. This plan also provides valuable everyday health benefits, including covered preventive services and home health care with no copay and no coinsurance. Vision coverage includes routine exams with copays up to $55 and up to $200 annually for eyewear with no copay, while dental benefits offer covered services with no copay up to a $250 yearly maximum. Additionally, members receive an $87 over-the-counter allowance every three months and routine hearing exams for a $55 copay.
Inpatient Hospital See details
Inpatient hospital services are covered by DEVOTED GIVEBACK 015 PA (HMO) with no coinsurance and a copay of $425 per day for days 1 through 4, followed by no copay for days 5 through 90. Unlimited additional days are covered for acute care, though upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED GIVEBACK 015 PA (HMO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital services require a copay of $0 to $525, observation services carry a $425 copay per stay, and outpatient substance abuse sessions have a $50 copay, with prior authorization required for most of these services.
Partial Hospitalization See details
DEVOTED GIVEBACK 015 PA (HMO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to access this covered benefit.
Ambulance and Transportation Services See details
DEVOTED GIVEBACK 015 PA (HMO) covers ambulance services with prior authorization, featuring a copay ranging from no copay to $355 and no coinsurance for ground services, and a 20% coinsurance with no copay for air services. Transportation services to health-related locations are not covered.
Emergency Services See details
DEVOTED GIVEBACK 015 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, 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 lifetime maximum with a $115 copay and no coinsurance, while worldwide emergency transportation requires a $355 copay and 20% coinsurance.
Primary Care See details
DEVOTED GIVEBACK 015 PA (HMO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $55 copay and no coinsurance. Physical and occupational therapies require copays of $35 to $55 with no coinsurance, while podiatry is not covered, and only some chiropractic services are covered with a $15 copay and no coinsurance since routine and other chiropractic care are not covered.
Preventive Services See details
Preventive services are partially covered by DEVOTED GIVEBACK 015 PA (HMO) with no copay and no coinsurance for covered benefits like annual physical exams, fitness programs, and nutritional training. Sub-services that are not covered under this plan include in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED GIVEBACK 015 PA (HMO), which offers routine hearing exams with a $55 copay, no coinsurance, and no deductible. Prescription hearing aids are covered up to two per year with a copay ranging from $599 to $899 and no coinsurance, 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 DEVOTED GIVEBACK 015 PA (HMO), as other eye exam services are not covered. Routine eye exams are covered once per year with a copay ranging from no copay to $55 and no coinsurance, while eyewear is covered with no copay, no coinsurance, and no deductible up to a $200 annual limit.
Dental Services See details
Dental services are partially covered by DEVOTED GIVEBACK 015 PA (HMO), which offers Medicare-covered dental services for a $55 copay and no coinsurance, and other covered dental services with no copay and no coinsurance up to a $250 yearly maximum. While preventive and most comprehensive services are covered, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED GIVEBACK 015 PA (HMO) with no copay, subject to prior authorization. Medicare Part B chemotherapy, radiation, and other drugs have no copay and between no coinsurance and 20% coinsurance, while Medicare Part B insulin has a $35 copay and between no coinsurance and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED GIVEBACK 015 PA (HMO) plan with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
DEVOTED GIVEBACK 015 PA (HMO) covers medical equipment with no copays, though coinsurance and prior authorization requirements apply. Durable medical equipment requires 17% coinsurance, while prosthetics and medical supplies carry no coinsurance to 20% coinsurance. Diabetic equipment is partially covered, offering diabetic supplies with no coinsurance to 17% coinsurance, but diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 015 PA (HMO) covers diagnostic and radiological services with prior authorization required. Diagnostic lab services, outpatient X-rays, and diagnostic radiological services have no copay, diagnostic procedures and tests have a copay ranging from $0 to $95 with no coinsurance, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the DEVOTED GIVEBACK 015 PA (HMO) plan with no copay and no coinsurance. Prior authorization is required to receive these services.
Cardiac Rehabilitation Services See details
DEVOTED GIVEBACK 015 PA (HMO) covers some cardiac rehabilitation services with no copay and no coinsurance, though prior authorization is required. However, 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 015 PA (HMO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and additional days beyond the standard 100 days are not covered.
Other Services See details
DEVOTED GIVEBACK 015 PA (HMO) partially covers other services, providing over-the-counter (OTC) items up to $87 every three months and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and other services in this category are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved