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DEVOTED GIVEBACK 002 HI (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 002 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 002 HI (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 002 HI (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Kauai and Maui Counties. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED GIVEBACK 002 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 002 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 002 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 $160.00. 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 002 HI (HMO) Medicare plan features an annual drug deductible of $605. During the initial coverage phase, Tier 1 preferred generic drugs are covered with no copay for 1-month, 2-month, and 3-month supplies at standard pharmacies and through standard mail order. Tier 2 generic drugs have a $3.00 copay for a 1-month supply, with 3-month supplies costing $9.00 at standard pharmacies and a reduced $7.50 through standard mail order. For higher-tier medications, cost sharing transitions to a percentage of the drug cost. Tier 3 preferred brand drugs require a 21% coinsurance for standard pharmacy and mail order fills. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance, with Tier 5 coverage limited to a 1-month supply.
Additional Benefits
The DEVOTED GIVEBACK 002 HI (HMO) plan offers robust coverage with no copay or coinsurance for primary care visits, preventive services, and home health care. Specialist visits require a $55 copay, while inpatient hospital stays cost $375 per day for the first four days followed by no copay for days five through 90. Emergency room visits have a $115 copay, which is waived if you are admitted, and urgent care copays range from no copay to $40. Diagnostic labs, X-rays, and basic dental and vision services are available with no copay, though dental benefits have a $250 annual maximum and vision eyewear is capped at $200 yearly. For medical needs, durable medical equipment requires no copay but carries a 14% coinsurance, while dialysis services require a 20% coinsurance with no copay. Prescription hearing aids are also covered with copays ranging from $599 to $899 per device for up to two devices per year.
Inpatient Hospital See details
DEVOTED GIVEBACK 002 HI (HMO) inpatient hospital services are partially covered with no coinsurance and a copay of $375 per day for days 1 through 4, followed by no copay for days 5 through 90. Prior authorization is required, and while unlimited additional acute days are covered, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED GIVEBACK 002 HI (HMO) with no coinsurance for all services, though prior authorization is required. Members will pay no copay for ambulatory surgical center and outpatient blood services, a $50 copay for outpatient substance abuse sessions, a $375 copay per stay for observation services, and a copay ranging from no copay to $425 for outpatient hospital services.
Partial Hospitalization See details
Partial hospitalization is covered under the DEVOTED GIVEBACK 002 HI (HMO) plan with a $70.00 copay and no coinsurance, although prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by DEVOTED GIVEBACK 002 HI (HMO), with prior-authorized ground ambulance services requiring a $0 to $350 copay and no coinsurance, and air ambulance services requiring 20% coinsurance and no copay. For transportation, some services are covered but transportation to plan-approved locations and any health-related locations is not covered.
Emergency Services See details
DEVOTED GIVEBACK 002 HI (HMO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a copay ranging from no copay to $40 with no coinsurance, while worldwide emergency services are covered up to $25,000 with a $115 copay and no coinsurance for medical care, and a $350 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 002 HI (HMO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $55 copay and no coinsurance. Physical, occupational, and mental health therapies are covered with copays ranging from $35 to $55 and no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are covered by DEVOTED GIVEBACK 002 HI (HMO) with no copay and no coinsurance, including annual physical exams and kidney disease education. Additional preventive benefits are partially covered, excluding in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access technologies, and counseling.
Hearing Services See details
Hearing services are covered by DEVOTED GIVEBACK 002 HI (HMO), offering one annual routine hearing exam for a $55 copay and no coinsurance, alongside unlimited fitting evaluations with no copay or coinsurance. Prescription hearing aids are partially covered with a copay ranging from $599 to $899 and no coinsurance for up to two devices per year, though OTC, inner ear, outer ear, and over-the-ear models are not covered.
Vision Services See details
DEVOTED GIVEBACK 002 HI (HMO) vision services are partially covered, offering eye exams 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, providing a combined maximum benefit of $200 per year for contacts, eyeglasses, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED GIVEBACK 002 HI (HMO), featuring a $55 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for other covered dental services up to a $250 annual maximum. While most preventive and comprehensive services are included, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED GIVEBACK 002 HI (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs have no copay and a coinsurance of 0% to 20%, while covered insulin has a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED GIVEBACK 002 HI (HMO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED GIVEBACK 002 HI (HMO) covers durable medical equipment, prosthetics, and medical supplies with no copay, requiring a 14% coinsurance for DME and up to 18% coinsurance for prosthetics and supplies. Diabetic equipment is partially covered with no copay and up to 14% coinsurance, but diabetic therapeutic shoes and inserts are not covered. Prior authorization is required for these medical equipment benefits.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 002 HI (HMO) offers diagnostic and radiological services with no copay or coinsurance for lab services, outpatient X-rays, and diagnostic radiology. Diagnostic procedures and tests require a copay between $0 and $95 with no coinsurance, while therapeutic radiological services incur a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED GIVEBACK 002 HI (HMO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED GIVEBACK 002 HI (HMO) covers Cardiac Rehabilitation Services with no coinsurance, though prior authorization is required. While some services are covered, cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 002 HI (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but allowing admission without a prior 3-day hospital stay. There is no copay for days 1 through 20 and a $185 copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED GIVEBACK 002 HI (HMO) partially covers other services, providing unlimited acupuncture and additional preventive services with no copay and no coinsurance. However, over-the-counter (OTC) items, meal benefits, and dual-eligible SNP services are not covered.
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