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Devoted GIVEBACK San Antonio (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted GIVEBACK San Antonio (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted GIVEBACK San Antonio (HMO) in 2025, please refer to our full plan details page.
Devoted GIVEBACK San Antonio (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in San Antonio. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Devoted GIVEBACK San Antonio (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 San Antonio (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 San Antonio (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 $172.70. 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 $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 $9350.00 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 San Antonio (HMO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590. Once you meet your deductible, you will pay a copay or coinsurance for your prescriptions depending on the tier and pharmacy you use. For preferred generic drugs, you will pay a $10 copay at standard and mail order pharmacies. For standard generic drugs, you will pay 25% coinsurance at standard and mail order pharmacies. For preferred brand drugs, you will pay 25% coinsurance at standard and mail order pharmacies. For non-preferred drugs, you will pay 25% coinsurance at standard and mail order pharmacies.
Additional Benefits
The Devoted GIVEBACK San Antonio (HMO) plan offers a range of health benefits, including coverage for inpatient and outpatient hospital services, with varying copays depending on the specific service. The plan also covers primary care, specialist visits, mental health services, and preventive services, all with their own copay amounts. Vision and dental services are covered, along with hearing exams and hearing aids. Additional benefits include ambulance services, emergency care, and home health services with no copay. The plan also covers skilled nursing facility stays, cardiac rehabilitation, and home infusion services with different cost-sharing structures. However, certain services like acupuncture, over-the-counter items, and some home-based care options are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered by this plan. For days 1-4, there is a $425 copay, and for days 5-90, there is no copay.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $525, observation services with a $425 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a $45 copay for individual and group sessions, and outpatient blood services. Prior authorization is required for some services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted GIVEBACK San Antonio (HMO) plan, with a $70 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted GIVEBACK San Antonio (HMO) plan. Ground ambulance services have a copay of $0-$350, and air ambulance services have a 20% coinsurance; transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Devoted GIVEBACK San Antonio (HMO) plan. Emergency Services have a $110 copay, and Urgently Needed Services have a copay between $0 and $45. Worldwide Emergency Transportation has a 20% coinsurance and a $350 copay, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay.
Primary Care See details
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 are covered. Chiropractic Services has a $15 copay, and Occupational Therapy Services has a $35 copay. Physician Specialist Services has a $45 copay. Individual and Group Mental Health and Psychiatric sessions, and Opioid Treatment Program Services have a $45 copay. Physical Therapy and Speech-Language Pathology Services have a copay between $45 and $50. Additional Telehealth Benefits have a copay between $0 and $45.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services, annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, kidney disease education, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit. The plan does not cover in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, readmission 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, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, and counseling services. Home and bathroom safety devices and modifications are covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $45 copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $599 and $899, while prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a $45 copay. Eyewear benefits are covered up to a combined maximum of $250 per year, and also include contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
The Devoted GIVEBACK San Antonio (HMO) plan covers Medicare Dental Services with a $45 copay, as well as 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. However, the plan does not cover maxillofacial prosthetics, implant services, or orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance; for Medicare Part B Chemotherapy/Radiation Drugs, there is between 0% and 20% coinsurance; and for Other Medicare Part B Drugs, there is between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted GIVEBACK San Antonio (HMO) plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 14% coinsurance and no copay, Prosthetic Devices with a 0-20% coinsurance and no copay, and Medical Supplies with a 14% coinsurance and no copay. Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
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 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Devoted GIVEBACK San Antonio (HMO) plan with no copay and no coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the specific services under this benefit are not covered. There is a copay for certain Cardiac and Pulmonary Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted GIVEBACK San Antonio (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 and non-Medicare-covered stays for Skilled Nursing Facility (SNF) are not covered.
Other Services See details
The "Devoted GIVEBACK San Antonio (HMO)" plan's other services benefit does not cover acupuncture, over-the-counter items, meal benefits, 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. Other services include $0 preventive services.
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