Devoted GIVEBACK Colorado (HMO-POS) Plan Details for Boulder County, CO
This plan has not been rated by CMS.
Devoted GIVEBACK Colorado (HMO-POS) is a Medicare Advantage plan with a prescription drug plan. 2025 plan enrollment starts Oct. 15.
See more Medicare Advantage Plans in Boulder County, Colorado.
2025 Devoted GIVEBACK Colorado Cost and Coverage Notification
The 2025 cost and coverage information for Devoted GIVEBACK Colorado will not be available until early October. We'll notify you as soon as it is available from CMS.
Sign-Up for 2025 Medicare Plan Notification. The 2025 Annual Enrollment Period begins October 15.
Devoted GIVEBACK Colorado Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | H7147-005-0 |
| Plan Type: | Local HMO |
| Plan Year: | 2024 |
| Premium: | $0.00/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | $5,900/yr |
| Part B Reduction: | $115.00/mo |
| Drug Plan Benefit: | Enhanced, $150.00 deductible |
| Rx Gap Coverage: | Yes |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Boulder County, CO |
| Insured By: | Devoted Health |
| Summary of Benefits |
|---|
Devoted Health Out-of-Pocket Costs
This Devoted Health Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H7147-005-0.
NOTE: Most preventive services are covered 100% by the plan as a Part B benefit.
| Healthcare Service | Member Cost |
|---|---|
| Doctor Visits (In-Network) | |
| Primary: | $0 |
| Specialist: | $40 Copay |
| Wellness programs (e.g., fitness, nursing hotline): | None |
| Preventive care: | $0 |
| Foot Care (In-Network) | |
| Foot exams and treatment (Medicare-covered): | $40 Copay |
| Routine foot care: | Not Covered |
| Chiropractic Care (In-Network) | |
| Medicare-covered chiropractic care: | $20 Copay |
| Routine chiropractic care: | Not Covered |
| Emergency Care / Urgent Care | |
| Emergency room care: | $120 Copay |
| Urgent care: | $50 Copay |
| Ground ambulance: | $275 Copay |
| Inpatient hospital coverage: | $350.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
| Outpatient hospital coverage: | $250 Copay Prior Authorization Required |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $203.00 per day for days 21 through 50 $0.00 per day for days 51 and beyond |
| Optional supplemental benefits: | |
| Mental Health Services (In-Network) | |
| Outpatient individual therapy visit with a psychiatrist: | $40 Copay |
| Outpatient group therapy visit with a psychiatrist: | $40 Copay |
| Inpatient hospital - psychiatric: | $350.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
| Outpatient group therapy visit: | $40 Copay |
| Outpatient individual therapy visit: | $0 |
| Rehabilitation Services (In-Network) | |
| Physical therapy and speech and language therapy visit: | $40 Copay |
| Occupational therapy visit: | $40 Copay |
| Medical Equipment / Supplies (In-Network) | |
| Diabetes supplies: | $0 |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Prior Authorization Required |
| Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
| Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
| Diagnostic radiology services (e.g., MRI): | $150 Copay Prior Authorization Required |
| Lab services: | $0 |
| Outpatient x-rays: | $25 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | $40 Copay Prior Authorization Required |
| Medicare Part B Drugs (In-Network) | |
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Devoted GIVEBACK Colorado Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits Devoted Health includes with this plan:
| Supplemental Healthcare Service | Member Cost |
|---|---|
| Preventive Dental | |
| Oral exam (In-Network) | Not Covered |
| Fluoride treatment (In-Network) | Not Covered |
| Dental x-ray(s) (In-Network) | Not Covered |
| Cleaning (In-Network) | Not Covered |
| Comprehensive Dental | |
| Periodontics (In-Network) | Not Covered |
| Non-routine services (In-Network) | Not Covered |
| Diagnostic services (In-Network) | Not Covered |
| Extractions (In-Network) | Not Covered |
| Endodontics (In-Network) | Not Covered |
| Restorative services (In-Network) | Not Covered |
| Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
| Hearing Aids | |
| Fitting/evaluation (In-Network) | Covered Limits may apply |
| Hearing aids (In-Network) | Covered Limits may apply |
| Hearing exam (In-Network) | Covered Limits may apply |
| Vision | Maximum vision benefit: | $200.00 Every year |
| Eyeglasses (frames and lenses) (In-Network) | Covered Limits may apply |
| Routine eye exam (In-Network) | Covered Limits may apply |
| Contact lenses (In-Network) | Covered Limits may apply |
Additional Benefits
None specified.
Prescription Drug Plan Costs & Benefits
Devoted GIVEBACK Colorado includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans have a higher actuarial value than basic plans. Actuarial value simply refers to the percentage of cost that's covered by the plan.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. LIS, also known as Extra Help, is a Social Security program that helps people with limited income and resources lower or cut Part D costs.
The following table outlines the premium details of this prescription drug plan.
| Basic Part D Premium: | $0.00 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $0.00 |
| Part D Premium with Full LIS Assistance: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $150.00. You must pay this amount at the pharmacy before Devoted Health begins paying its share.
NOTE: The deductible does not apply to one or more drug tiers in this plan (see "Prescription Drug Plan Out-of-Pocket Costs" below).
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Devoted GIVEBACK Colorado has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Preferred | Standard |
|---|---|---|
| 1 (Preferred Generic) | N/A | $0.00 copay (deductible does not apply) |
| 2 (Generic) | N/A | $9.00 copay |
| 3 (Preferred Brand) | N/A | $47.00 copay |
| 4 (Non-Preferred Drug) | N/A | $95.00 copay |
| 5 (Specialty Tier) | N/A | 30% |
CMS 5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories using a 5-star rating system. Here are the most recent CMS ratings for Devoted GIVEBACK Colorado.
| CMS Measure | Star Rating |
|---|---|
| 2024 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | Plan too new to be measured |
| Managing Chronic (Long Term) Conditions | Plan too new to be measured |
| Member Experience with Health Plan | Plan too new to be measured |
| Complaints and Changes in Plans Performance | Plan too new to be measured |
| Health Plan Customer Service | Plan too new to be measured |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | Plan too new to be measured |
| Member Experience with the Drug Plan | Plan too new to be measured |
| Drug Safety and Accuracy of Drug Pricing | Plan too new to be measured |
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact Devoted Health
| Plan Website: | http://www.Devoted.com |
|---|---|
| Formulary Information: | http://www.Devoted.com |
| Pharmacy Information: | Devoted Health Pharmacy Page |
| Prospective Members: | (800)376-5889 |
| TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- Devoted Health, http://www.Devoted.com, Last Accessed February 20, 2024
- Medicare.gov, "Medicare Advantage Plans cover all Medicare services", Last Accessed February 20, 2024
- Medicare.gov, "Compare Original Medicare & Medicare Advantage", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.