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DEVOTED GIVEBACK 001 HI (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 001 HI (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED GIVEBACK 001 HI (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 001 HI (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Honolulu County. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED GIVEBACK 001 HI (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 001 HI (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 001 HI (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 $159.90. 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 $605.00 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 $8300.00 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 001 HI (HMO) Medicare plan features an annual drug deductible of $605. For Tier 1 preferred generic drugs, members pay no copay for one-month, two-month, or three-month supplies filled at standard pharmacies or through standard mail order. Tier 2 generic drugs are also highly affordable, with copays ranging from $1 to $3 at standard pharmacies and $1 to $2.50 for standard mail order depending on the supply duration. For higher-tier medications, the plan utilizes coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 24% coinsurance for standard pharmacy and standard mail order fills. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance, with specialty tier coverage limited to a one-month supply.
Additional Benefits
The DEVOTED GIVEBACK 001 HI (HMO) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care visits, home health services, and routine preventive care. For specialized care and hospital stays, members can expect a $55 copay for specialist visits, a $115 copay for emergency services, and a daily copay of $375 for the first four days of inpatient hospital stays. Outpatient hospital services and surgeries are also covered with no coinsurance and copays ranging from no copay up to $375. This plan also features dental, vision, and hearing benefits, including no copays for routine dental and eyewear up to specific annual limits, alongside a $55 copay for routine hearing exams. Additionally, skilled nursing facility stays require no copay for the first 20 days, while durable medical equipment is covered with no copay and a 15% coinsurance. While acupuncture is fully covered with no copay, please note that this plan does not cover routine transportation, over-the-counter items, or meal benefits.
Inpatient Hospital See details
DEVOTED GIVEBACK 001 HI (HMO) covers inpatient hospital services with no coinsurance, requiring a $375 daily copay for days 1 through 4 and no copay for days 5 through 90. This partially covered benefit includes unlimited additional days for acute care, but does not cover additional psychiatric days, upgrades, or non-Medicare-covered stays.
Outpatient Services See details
Outpatient services are covered by DEVOTED GIVEBACK 001 HI (HMO) with no coinsurance, including ambulatory surgical center and blood services with no copay. Outpatient hospital services require a copay of $0 to $375, observation services carry a $375 copay per stay, and individual or group substance abuse sessions cost a $50 copay.
Partial Hospitalization See details
DEVOTED GIVEBACK 001 HI (HMO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
DEVOTED GIVEBACK 001 HI (HMO) covers ground ambulance services with a copay of up to $315 (with no copay for some services) and coinsurance, and air ambulance services with a 20% coinsurance and a copay, both requiring prior authorization. Transportation services are not covered under this plan.
Emergency Services See details
Emergency services are covered by DEVOTED GIVEBACK 001 HI (HMO) with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services feature a copay ranging from no copay to $40 with no coinsurance, and worldwide emergency services are covered up to $25,000 with a $115 copay and no coinsurance for emergency or urgent care, and a $315 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 001 HI (HMO) provides primary care physician services with no copay and no coinsurance, while specialist visits require a $55 copay and no coinsurance. Physical, occupational, and speech therapies, along with mental health, psychiatric, and telehealth services, are covered with copays ranging from $0 to $55 and no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by DEVOTED GIVEBACK 001 HI (HMO) with no copay and no coinsurance for covered benefits like annual physicals, kidney education, and fitness programs. However, certain sub-services are not covered, including in-home support, personal emergency response systems, medical nutrition therapy, in-home safety assessments, and counseling.
Hearing Services See details
Hearing services covered by the DEVOTED GIVEBACK 001 HI (HMO) plan include one routine exam per year for a $55 copay and no coinsurance, with no deductible. Prescription hearing aids are partially covered with copays ranging from $599 to $899 and no coinsurance for up to two aids per year, but OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
DEVOTED GIVEBACK 001 HI (HMO) covers vision services, featuring one annual routine eye exam with a $0 to $20 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $200 yearly maximum for contacts, lenses, frames, and upgrades.
Dental Services See details
DEVOTED GIVEBACK 001 HI (HMO) covers dental services with a $55 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other preventive and comprehensive services up to a $250 annual maximum. These dental services are partially covered, as maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED GIVEBACK 001 HI (HMO) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs carry no copay and a coinsurance ranging from no coinsurance up to 20%, while Part B insulin requires a $35 copay and a coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED GIVEBACK 001 HI (HMO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED GIVEBACK 001 HI (HMO) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment carries a 15% coinsurance, while covered prosthetics, medical supplies, and diabetic supplies range from no coinsurance to 15% coinsurance. Diabetic equipment is partially covered, as diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED GIVEBACK 001 HI (HMO) with prior authorization. Diagnostic tests and lab services require no coinsurance and copays from $0 to $95, while diagnostic radiology has no copay, X-rays have no copay but require coinsurance, and therapeutic services require a copay and a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED GIVEBACK 001 HI (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED GIVEBACK 001 HI (HMO) covers some services with no copay and no coinsurance, but cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 001 HI (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20 and a $218 copay for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered under DEVOTED GIVEBACK 001 HI (HMO), which offers unlimited acupuncture and additional preventive services with no copay and no coinsurance. Over-the-counter (OTC) items, meal benefits, and other miscellaneous services are not covered under this plan.
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