Devoted GIVEBACK Oregon (HMO)
Devoted GIVEBACK Oregon (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H2923-004
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Devoted GIVEBACK Oregon (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H2923-004
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $590 |
Out of Pocket Max |
In-Network: $7900 Out-of-Network: N/A |
Initial Coverage Limit | $2000 |
Catastrophic Coverage Limit | $2,000 |
Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $50 |
Inpatient Hospital Care | Inpatient Hospital Coverage:
|
Urgent Care | Copayment for Urgent Care $0 to $45 $0 copay for urgently needed services received by a PCP.$45 copay for urgently needed services received from an urgent care center. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110 |
Emergency Room Visit | Copayment for Emergency Care $110 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $110 Copayment for Worldwide Emergency Transportation $350 |
Ambulance Transportation | Ground Ambulance $350 PA may be required Air or Water Ambulance 20% PA may be required Facility to Facility Transfer Member will not be responsible for additional ground ambulance copays for facility to facility transfers. |
Health Care Services and Medical Supplies
Devoted GIVEBACK Oregon (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
Coverage | Cost |
---|---|
Chiropractic Services | Chiropractic Services - Medicare Covered Copayment $15 Chiropractic Services - Routine Visits Copayment Not covered |
Diabetes Supplies, Training, Nutrition Therapy and Monitoring | Copayment for Medicare-covered Diabetic Supplies $0 PA may be required Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 PA may be required |
Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 15% Prior Authorization Required for Durable Medical Equipment Prior authorization required |
Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $95 Copayment for Medicare-covered Lab Services $0 to $40 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Copayment varies based on site of service:PCPs office: $0 copay for EKGs/EEGs/ECGs, $0 copay all other. Specialist office: $0 copay for EKGs/EEGs/ECGs, $40 copay all other. Freestanding facility: $40 copay for EKGs/EEGs/ECGs, $40 copay all other. Outpatient hospital: $95 copay for EKGs/EEGs/ECGs, $95 copay all other. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $300 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $75 Prior authorization required |
Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Prior authorization required |
Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $375 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required |
Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $45 Copayment for Medicare-covered Group Sessions $45 |
Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $475 Prior Authorization Required for Outpatient Hospital Services $0 copay for diagnostic colonoscopies, $475 copay for all other outpatient hospital services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $385 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $385 Prior Authorization Required for Ambulatory Surgical Center Services $0 copay for diagnostic colonoscopies, $385 copay for all other ASC services. Prior authorization required |
Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $45 Copayment for Medicare-covered Group Sessions $45 |
Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $50 |
Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $170 per day for days 21 to 60 $0 per day for days 61 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
Coverage | Cost |
---|---|
Dental Care | This plan has a: Dental/Eyewear/Alt Therapy Allowance. Copayment for Medicare Covered Dental Services: $50 PA may be required Preventive & Comprehensive Dental Services: You have a $250 yearly allowance toward Preventive Dental, Comprehensive Dental, Eyewear, Therapeutic Massage, Routine Acupuncture, and/or Naturopath Services combined. You can see any licensed provider or visit any eyewear retailer. You'll pay the costs yourself at first. Then, you can submit a request for reimbursement to Devoted. Cosmetic procedures, dental implants, elective procedures, herbs, homeopathic remedies, medications and nutritional supplements, vitamins and/or vitamin injections are not covered. Please see Summary of Benefits and Evidence of Coverage for more benefit information. |
Vision Benefits
The following vision services are covered from in-network providers.
Coverage | Cost |
---|---|
Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $20 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $250 every year. Allowance may be combined with comprehensive dental benefits. Please see Summary of Benefits and Evidence of Coverage for more benefit information. |
Hearing Benefits
The following hearing services are covered from in-network providers.
Coverage | Cost |
---|---|
Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $50 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $599 to $899
|
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
Coverage | Cost |
---|---|
Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The Devoted GIVEBACK Oregon (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $590 (excludes Tiers 1 and 2) per year.
Coverage |
Cost
|
---|---|
Coverage & Cost
|
|
Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
Preferred Generic |
|
Generic |
|
Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
Preferred Generic |
|
Generic |
|
Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
Preferred Generic |
|
Generic |
|