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DEVOTED GIVEBACK 012 VA (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 012 VA (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED GIVEBACK 012 VA (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 012 VA (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Southwest Virginia. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED GIVEBACK 012 VA (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 012 VA (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 012 VA (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 012 VA (HMO) Medicare plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs have no copay for one-month, two-month, and three-month supplies at standard pharmacies and through standard mail order. Tier 2 generic drugs require a low $3.00 copay for a one-month supply, with standard mail order offering a discounted $7.50 copay for a three-month supply. For brand-name and specialty medications, members pay coinsurance rather than flat copayments. Tier 3 preferred brand drugs require a 21% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance. Specialty drugs under Tier 5 are limited to a one-month supply at standard pharmacies and through standard mail order.
Additional Benefits
The DEVOTED GIVEBACK 012 VA (HMO) plan offers comprehensive medical coverage featuring no copay for primary care visits, preventive services, and home health care. Specialist visits require a $55 copay, while inpatient hospital stays incur a $475 daily copay for the first 3 days and no copay for days 4 through 90. Emergency care is covered with a $115 copay, which is waived if you are admitted to the hospital within 24 hours. For ancillary care, the plan provides routine eyewear and dental services with no copay up to specified annual limits of $200 and $250 respectively. Prescription hearing aids carry copays between $599 and $899, and routine hearing exams require a $55 copay. Members also benefit from no copay for durable medical equipment with a 15% coinsurance, alongside a $93 quarterly allowance for over-the-counter items.
Inpatient Hospital See details
DEVOTED GIVEBACK 012 VA (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $475 daily copay for days 1 to 3 and no copay for days 4 to 90. Unlimited additional days are covered for acute care, but psychiatric additional days, room upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services covered by DEVOTED GIVEBACK 012 VA (HMO) feature no coinsurance, including no copay for ambulatory surgical center and blood services. Patients will pay a copay of $0 to $575 for outpatient hospital services, $475 per stay for observation services, and $50 per session for outpatient substance abuse services.
Partial Hospitalization See details
Partial hospitalization is covered by the DEVOTED GIVEBACK 012 VA (HMO) plan with an $80.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under the DEVOTED GIVEBACK 012 VA (HMO) plan, featuring a copay ranging from no copay to $315 for ground ambulance services and a 20% coinsurance for air ambulance services. While some transportation services are covered, transportation to plan-approved health-related locations and any health-related locations are not covered.
Emergency Services See details
DEVOTED GIVEBACK 012 VA (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 range from no copay to a $40 copay with no coinsurance, and worldwide emergency services are covered up to a $25,000 limit with a $115 copay for care and a $315 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 012 VA (HMO) provides primary care physician services with no copay and no coinsurance, while specialist visits carry a $55 copay and no coinsurance. Occupational therapy requires a $35 copay, physical and speech therapy require a $55 copay, and mental health services require a $50 copay, all with no coinsurance. Podiatry services are not covered, and chiropractic services are partially covered, excluding routine chiropractic care and other chiropractic services.
Preventive Services See details
Preventive Services are partially covered by DEVOTED GIVEBACK 012 VA (HMO) with no copay and no coinsurance for covered benefits like annual physical exams, fitness programs, and alternative therapies. While many services are included, several are not covered, such as in-home safety assessments, personal emergency response systems, medical nutrition therapy, therapeutic massage, and adult day health services.
Hearing Services See details
DEVOTED GIVEBACK 012 VA (HMO) covers hearing services, offering routine hearing exams for a $55 copay and no coinsurance, and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $599 to $899 for up to two aids per year, though inner ear, outer ear, over the ear, and over-the-counter hearing aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED GIVEBACK 012 VA (HMO), featuring one routine eye exam per year with a $0 to $55 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $200 annual maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED GIVEBACK 012 VA (HMO) dental services are partially covered, featuring a $55 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for other dental services up to a $250 annual maximum. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED GIVEBACK 012 VA (HMO) covers home infusion bundled services with no copay, subject to prior authorization and step therapy. Medicare Part B drugs, including chemotherapy and radiation, have up to 20% coinsurance, while covered Part B insulin requires a $35 copay and up to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by DEVOTED GIVEBACK 012 VA (HMO) with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED GIVEBACK 012 VA (HMO) partially covers medical equipment with no copays, featuring a 15% coinsurance for durable medical equipment, no coinsurance to 20% coinsurance for prosthetics and medical supplies, and no coinsurance to 15% coinsurance for diabetic supplies. Diabetic therapeutic shoes and inserts are not covered, and prior authorization is required for covered equipment.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the DEVOTED GIVEBACK 012 VA (HMO) plan, with prior authorization required for these benefits. Lab services, outpatient X-rays, and diagnostic radiological services feature no copay, while diagnostic tests carry a copay of $0 to $95 with no coinsurance, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the DEVOTED GIVEBACK 012 VA (HMO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED GIVEBACK 012 VA (HMO) with no coinsurance, though prior authorization is required. Some services are covered, but cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered, carrying copays of $30, $30, $25, and $20 respectively.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 012 VA (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, and the benefit is partially covered because additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
DEVOTED GIVEBACK 012 VA (HMO) partially covers other services, offering additional preventive services and over-the-counter (OTC) items up to $93 every three months with no copay and no coinsurance. Acupuncture, meal benefits, and dual eligible SNP services are not covered under this plan.
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