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Devoted GIVEBACK North Carolina (HMO)
Devoted CORE North Carolina (HMO)

Want help enrolling? Give us a call.

Devoted GIVEBACK North Carolina (HMO)

Summary of Benefits (PDF)
Updated August 30, 2023

Devoted CORE North Carolina (HMO)

Summary of Benefits (PDF)
Updated August 30, 2023

Monthly Premium

$0

Also, your Part B premium is reduced by up to $130 per month.

$0

You must continue to pay your part B premium.

Part B Giveback

This amount goes back into your Social Security check each month.

Up to $130 per month

None

Annual Out-of-Pocket Maximum

This is the most you'll pay in a year for Medicare covered medical services. Your out-of-pocket Part D drug costs don't count toward this amount.

$6,700

$3,900

Primary Care Provider (PCP) Visits

$0 copay*

$0 copay*

Specialist Visits

$45 copay*

$20 copay*

Inpatient Hospital Stays

Days 1 - 4
$440 copay per day

Day 5+
$0 copay per day*

Days 1 - 5
$295 copay per day

Day 6+
$0 copay per day*

Outpatient Surgery

Ambulatory surgery centers are different from hospitals and focus just on outpatient surgery.

  • $295 copay* at an ambulatory surgery center
  • $395 copay* at an outpatient hospital

  • $195 copay* at an ambulatory surgery center
  • $275 copay* at an outpatient hospital

Emergency Room Visit

If admitted to the hospital within 24 hours, you won't have a copay for emergency care.

$100 copay per stay

$120 copay per stay

Urgent Care Center Visit

To treat a non-emergency illness, injury, or condition that requires immediate medical care.

$50 copay

$30 copay

Labs

If the lab is part of a hospital system, you might pay the higher copay. Call us to find out.

$0 copay*

$0 copay*

X-rays and Ultrasounds

If the provider is part of a hospital system, you might pay the higher copay. Call us to find out.

  • $0 copay in an office or freestanding location*
  • $50 copay at an outpatient hospital setting*

  • $0 copay in an office or freestanding location*
  • $75 copay at an outpatient hospital setting*

Diagnostic Tests and Procedures

If the provider is part of a hospital system, you might pay the higher copay. Call us to find out.

  • $0 copay in an office or freestanding location*
  • $50 copay at an outpatient hospital setting*

  • $0 copay in an office or freestanding location*
  • $20 copay at an outpatient hospital setting*

Pharmacy (Part D) Deductible

$395 for Tiers 3-5 only

If you receive "Extra Help" from Medicare, your deductible will be $0.

The deductible does not apply to covered Part D insulins and most adult Part D vaccines.

This plan does not have a deductible.

30-Day Supply Retail Pharmacy

If you get Extra Help from Medicare, your costs may be lower.

  • Tier 1: $0 per prescription
  • Tier 2: $5 per prescription
  • Tier 3: $47 per prescription
  • Tier 4: $100 per prescription
  • Tier 5: 27% of the total cost

  • Tier 1: $0 per prescription
  • Tier 2: $5 per prescription
  • Tier 3: $47 per prescription
  • Tier 4: $100 per prescription
  • Tier 5: 33% of the total cost

100-Day Supply Mail-Order Pharmacy

If you get Extra Help from Medicare, your costs may be lower.

  • Tier 1: $0 per prescription
  • Tier 2: $12.50 per prescription
  • Tier 3: $117.50 per prescription
  • Tier 4: $300 per prescription
  • Tier 5: Not available through mail

  • Tier 1: $0 per prescription
  • Tier 2: $12.50 per prescription
  • Tier 3: $117.50 per prescription
  • Tier 4: $300 per prescription
  • Tier 5: Not available through mail

Erectile Dysfunction Drugs

Sildenafil (Viagra) and tadalfil (Cialis) are covered medications for up to 6 pills a month.

$5 per prescription*

$5 per prescription*

Dental

$500 on a pre-loaded debit card toward Dental Services

$1,500 on a pre-loaded debit card toward Dental Services

Food & Home Card

Pre-loaded card for purchase of groceries, utilities, mortgage, or rent

Not covered

$40 per month

The Food & Home Card is available to members with eligible chronic health conditions.

Over-the-Counter Credit

For items like toothpaste, vitamins, blood pressure cuffs, and more

Not covered

$70 per quarter (every 3 months)

Medical Alert Device

Call for emergency help with the press of a button.

Free device and free monthly monitoring*

Free device and free monthly monitoring*

Hearing Aids

Plan covers 2 hearing aids a year, plus free batteries.

  • $599 copay per ear for Advanced Aids*
  • $899 copay per ear for Premium Aids*

  • $399 copay per ear for Advanced Aids*
  • $699 copay per ear for Premium Aids*

Vision

  • $0 copay for yearly routine eye exam*
  • $200 toward glasses or contacts
  • Free contact lens fitting

  • $0 copay for yearly routine eye exam*
  • $350 toward glasses or contacts
  • Free contact lens fitting

Fitness

  • Free SilverSneakers membership*
  • $150 per year to spend on fitness trackers, home gym equipment, and more

  • Free SilverSneakers membership*
  • $150 per year to spend on fitness trackers, home gym equipment, and more

*When you use an in-network provider or pharmacy.


Next Steps

Now that you know what our plans are all about, you can:

And if you have any questions, call us at (1-800-990-0723) (TTY 711) You can also see and compare more plan options at www.Medicare.gov.