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Devoted GIVEBACK Illinois (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted GIVEBACK Illinois (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted GIVEBACK Illinois (HMO) in 2025, please refer to our full plan details page.
Devoted GIVEBACK Illinois (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Greater Chicago. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Devoted GIVEBACK Illinois (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 Illinois (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 Illinois (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 $132.60. 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 $590.00 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 $8850.00 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 Illinois (HMO) plan has a $590 deductible for prescription drugs. Once you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For the Initial Coverage Phase, you'll pay $10 for preferred generic drugs at standard or mail-order pharmacies, or 25% coinsurance for standard generic, preferred brand, and non-preferred drugs. After your total drug costs reach $2,000, you enter the Catastrophic Coverage Phase, where you pay nothing for Part D covered drugs.
Additional Benefits
The Devoted GIVEBACK Illinois (HMO) plan offers a range of benefits, including coverage for inpatient hospital stays with a copay, outpatient services, and partial hospitalization. This plan also covers ambulance, emergency, and primary care services with varying copays, along with preventive, hearing, vision, and dental services. The plan also covers home infusion services, dialysis services, medical equipment, diagnostic and radiological services, home health services, cardiac rehabilitation, and skilled nursing facility stays. This plan includes coverage for a variety of additional services. There is no copay for preventive services, and there are also no copays for hearing aid fittings and evaluations. This plan covers prescription hearing aids, as well as eye exams and eyewear.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care with a $475 copay for days 1-4, and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $575, observation services with a $475 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services have a $45 copay for both individual and group sessions, and outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted GIVEBACK Illinois (HMO) plan, with a $70 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted GIVEBACK Illinois (HMO) plan, including ground ambulance services with a copay between $0 and $350, and air ambulance services with 20% coinsurance; however, transportation services to health-related locations are not covered. All ambulance services require prior authorization.
Emergency Services See details
Emergency Services are covered by the Devoted GIVEBACK Illinois (HMO) plan, with a $110 copay. Urgently Needed Services have a copay between $0 and $45, and Worldwide Emergency Services are also covered, with a $110 copay for Worldwide Emergency and Urgent Coverage, and a $350 copay and 20% coinsurance for Worldwide Emergency Transportation.
Primary Care See details
Primary Care includes coverage for Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services. Chiropractic Services have a $15 copay, Occupational Therapy Services have a $35 copay, Physician Specialist Services have a $45 copay, Individual and Group Sessions for Mental Health Specialty Services have a $45 copay, and Physical Therapy and Speech-Language Pathology Services have a $35 copay. Other Health Care Professional services have a copay between $0 and $45, while Individual and Group Sessions for Psychiatric Services, and Opioid Treatment Program Services have a $45 copay. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The Devoted GIVEBACK Illinois (HMO) plan covers preventive services, including Medicare-covered services with no copay, annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. However, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, and counseling services are not covered.
Hearing Services See details
Hearing Services include hearing exams, with a $40 copay for Routine Hearing Exams, and fitting/evaluation for hearing aids with no copay. Prescription Hearing Aids (all types) are covered with a copay between $599 and $899, but Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered, and OTC Hearing Aids are not covered.
Vision Services See details
Vision services include eye exams with a $40 copay, and eyewear with a combined maximum of $250 per year. This plan also covers contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
Dental services include coverage for Medicare dental services with a $45 copay, as well as other dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. Maxillofacial prosthetics, implant services, and orthodontics are not covered. There is a $250 maximum plan benefit for other dental services, and the benefit is available every year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted GIVEBACK Illinois (HMO) plan. There is a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 0-20% coinsurance and Prosthetic Devices with 0-20% coinsurance, but Durable Medical Equipment for use outside the home and Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered. Medical Supplies have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for diagnostic procedures and tests with a copay between $0 and $95, lab services with no copay, and outpatient X-ray services with no copay. Diagnostic radiological services have a copay up to $300, and therapeutic radiological services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Devoted GIVEBACK Illinois (HMO) plan with no copay and no coinsurance, though authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but not the specific sub-services of Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. The plan has a copay for some cardiac and pulmonary rehabilitation services, but the specific amount is not listed.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted GIVEBACK Illinois (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services are not covered by the Devoted GIVEBACK Illinois (HMO) plan, including acupuncture, over-the-counter items, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services. The plan does cover other services, including $0 preventive services.
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