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DEVOTED GIVEBACK 003 IL (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 003 IL (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED GIVEBACK 003 IL (HMO) in 2026, please refer to our full plan details page.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
DEVOTED GIVEBACK 003 IL (HMO) is a HMO plan offered by Devoted Health Plan of Illinois, Inc. available for the 2026 plan year to people living in Greater Chicago. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 003 IL (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 003 IL (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 003 IL (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
Health deductible: information not available.
This plan has a $605.00 drug deductible that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $8850.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $8850.00 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 003 IL (HMO) Medicare plan has an annual prescription drug deductible of $605. You will pay no copay for Tier 1 preferred generic drugs, whether you fill a one-, two-, or three-month supply at a standard pharmacy or through standard mail order. Tier 2 generic drugs are also highly affordable, carrying a low copay of $3.00 for a one-month supply and up to $9.00 for a three-month supply. For brand-name and specialty medications, costs are calculated using coinsurance. Tier 3 preferred brand drugs require a 21% coinsurance, while Tier 4 non-preferred drugs require a 25% coinsurance for standard pharmacy and mail-order fills. Tier 5 specialty drugs also have a 25% coinsurance, which is limited to a one-month supply.
Additional Benefits
The DEVOTED GIVEBACK 003 IL (HMO) plan offers affordable healthcare coverage, featuring no copay and no coinsurance for primary care doctor visits and annual physicals. For specialized care, members pay a $45 copay for specialist visits, while inpatient hospital stays require a $475 daily copay for the first four days and no copay for days five through ninety. Emergency room visits have a $115 copay, which is completely waived if you are admitted to the hospital within 24 hours. Supplemental benefits are also highly accessible, offering routine dental and vision care with no copay up to yearly limits, alongside hearing exams for a $45 copay. Members also benefit from home health services with no copay and a $76 quarterly allowance for over-the-counter products with no copay or coinsurance. Skilled nursing facility stays are covered with no copay for the first twenty days, ensuring comprehensive support during recovery.
Inpatient Hospital See details
DEVOTED GIVEBACK 003 IL (HMO) covers inpatient hospital services with no coinsurance, requiring a $475 daily copay for days 1 through 4 and no copay for days 5 through 90. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric inpatient days are not covered.
Outpatient Services See details
DEVOTED GIVEBACK 003 IL (HMO) covers outpatient services with no coinsurance, featuring a $0 to $575 copay for outpatient hospital services and a $475 copay per stay for observation services. Ambulatory surgical center and outpatient blood services require no copay, while individual and group outpatient substance abuse sessions have a $45 copay.
Partial Hospitalization See details
Partial hospitalization is covered by DEVOTED GIVEBACK 003 IL (HMO) with a $70.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Ambulance services are covered by DEVOTED GIVEBACK 003 IL (HMO) with prior authorization, requiring a copay of no copay to $350 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 003 IL (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 limit with a $115 copay and no coinsurance, while worldwide emergency transportation has a $350 copay and 20% coinsurance.
Primary Care See details
DEVOTED GIVEBACK 003 IL (HMO) offers primary care physician visits with no copay and no coinsurance, while specialist and mental health specialty services require a $45 copay and no coinsurance. Physical and occupational therapy services have a $35 copay and no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
DEVOTED GIVEBACK 003 IL (HMO) partially covers preventive services with no copay and no coinsurance for covered benefits like annual physicals, fitness programs, and health education. Uncovered sub-services include in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, therapeutic massage, adult day health, palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access, and counseling.
Hearing Services See details
DEVOTED GIVEBACK 003 IL (HMO) covers hearing services with a $45 copay and no coinsurance for annual routine exams, alongside unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $599 to $899 for up to two aids per year, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
DEVOTED GIVEBACK 003 IL (HMO) offers partially covered vision services, with other eye exam services not covered. Covered eye exams have a $0 to $45 copay and no coinsurance, and eyewear is covered with no copay or coinsurance up to a $100 annual limit.
Dental Services See details
Dental services are partially covered by DEVOTED GIVEBACK 003 IL (HMO), featuring a $45 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other covered services up to a $250 annual maximum. While many preventive and comprehensive dental benefits are included, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED GIVEBACK 003 IL (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Part B chemotherapy, radiation, and other drugs have no copay and a coinsurance ranging from no coinsurance to 20%, while Part B insulin requires a $35 copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
DEVOTED GIVEBACK 003 IL (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 003 IL (HMO) offers partially covered medical equipment with no copays for covered items, though prior authorization is required. Durable medical equipment (DME) carries a 20% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance to 20% coinsurance, and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 003 IL (HMO) covers diagnostic and radiological services, with prior authorization required for both. Diagnostic services feature no coinsurance, offering lab services with no copay and diagnostic procedures with a copay ranging from $0 to $95. Radiological services include outpatient X-rays with no copay but applicable coinsurance, diagnostic radiology with copays starting at $0, and therapeutic radiology with a copay and a minimum 20% coinsurance.
Home Health Services See details
DEVOTED GIVEBACK 003 IL (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the DEVOTED GIVEBACK 003 IL (HMO) plan with no coinsurance and require prior authorization. While some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered in practice.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 003 IL (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient 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 standard Medicare-covered limit are not covered.
Other Services See details
DEVOTED GIVEBACK 003 IL (HMO) partially covers other services, with acupuncture, meal benefits, and certain other services not covered under the plan. Covered benefits include over-the-counter (OTC) items up to $76 every three months and additional preventive services, both of which are available with no copay and no coinsurance.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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