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Prominence Giveback $75 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Prominence Giveback $75 (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Prominence Giveback $75 (HMO) in 2025, please refer to our full plan details page.
Prominence Giveback $75 (HMO) is a HMO plan offered by Universal Health Services, Inc. available for enrollment in 2025 to people living in Washoe County. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Prominence Giveback $75 (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 Prominence Giveback $75 (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 Prominence Giveback $75 (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 $75.00. 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 $590.00 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 $6750.00 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 Prominence Giveback $75 (HMO) plan has a $590 deductible for prescription drugs. Once you meet your deductible, you will pay a copay or coinsurance depending on the drug tier. For drugs in the Standard Pharmacy, you'll pay a $12 copay for Tier 1 (Preferred Generic), 24% coinsurance for Tier 2 (Standard Generic), 40% coinsurance for Tier 3 (Preferred Brand), 25% coinsurance for Tier 4 (Non-Preferred Drug), and no copay for Tier 5 (Specialty Tier). The plan also offers Part D premium reductions for those who qualify for the low-income subsidy.
Additional Benefits
The Prominence Giveback $75 (HMO) plan offers a range of benefits, including coverage for inpatient hospital stays, outpatient services, and various specialist visits with copays. This plan includes coverage for vision and dental services, with a combined maximum of $200 per year for vision, and a wide range of dental services with varying copays. Additionally, the plan covers services like ambulance, emergency care, and home health services with specific copays or coinsurance, as well as coverage for hearing exams. This plan offers coverage for home infusion, dialysis, and medical equipment with coinsurance, and also covers skilled nursing facility services with copays for specific days. The plan also includes preventive services and covers some additional services such as fitness benefits, diabetes self-management training, and telemonitoring. However, the plan does not cover certain services, including specific vision and hearing services, alternative therapies, and some rehabilitation services.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $275 copay for days 1-6, and no copay for days 7-90; additional days, non-Medicare-covered stays, and upgrades are not covered. For Inpatient Hospital Psychiatric, you will pay a $330 copay for days 1-5, and no copay for days 6-90; additional days and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient hospital services have a copay between $25 and $350, observation services have a $295 copay, ambulatory surgical center services have a $100 copay, and outpatient substance abuse individual and group sessions have a copay between $10 and $10.
Partial Hospitalization See details
Partial Hospitalization is covered by the Prominence Giveback $75 (HMO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Prominence Giveback $75 (HMO) plan. Ground and air ambulance services each have a $300 copay, which is waived if admitted to the hospital, while transportation services to any health-related location are limited to 24 one-way trips per year.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage have a copay of $125, $10, and $125, respectively, with no coinsurance. Worldwide Urgent Coverage has a copay of $30 with no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Prominence Giveback $75 (HMO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $5 copay, and physician specialist services with a $45 copay. The plan also covers mental health specialty services with a $45 copay for individual and group sessions, and podiatry services and other health care professional services with copays ranging from $0 to $45. Physical therapy and speech-language pathology services have a $45 copay, and additional telehealth benefits and opioid treatment program services are covered with copays from $10 to $45.
Preventive Services See details
The Prominence Giveback $75 (HMO) plan covers preventive services, including Medicare-covered preventive services, annual physical exams, and additional preventive services. Additional services include In-Home Safety Assessment, Fitness Benefit, Telemonitoring Services, Remote Access Technologies, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. However, the plan does not cover Health Education, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Home and Bathroom Safety Devices and Modifications, and Counseling Services.
Hearing Services See details
Hearing Services include hearing exams with a $10 copay, but routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids (all types, inner ear, outer ear, and over the ear), and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $30 copay, and eyewear benefits including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames, with a combined maximum of $200 per year.
Dental Services See details
The Prominence Giveback $75 (HMO) plan covers dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services with a copay of $50-$100, adjunctive general services with a copay of $0-$50, endodontics with a $100 copay, periodontics with a copay of $0-$100, prosthodontics (removable) with a copay of $50-$100, prosthodontics (fixed) with a copay of $50-$100, and oral and maxillofacial surgery with a copay of $50-$100. Maxillofacial prosthetics and orthodontics are not covered, and implant services is an optional supplemental benefit.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Prominence Giveback $75 (HMO) plan. There is a 20% coinsurance for these services, and prior authorization is required.
Medical Equipment See details
Medical equipment is covered by the Prominence Giveback $75 (HMO) plan. You will pay 20% coinsurance for Durable Medical Equipment, Prosthetic Devices, and Medical Supplies.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, though Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered. For Diagnostic Radiological Services, there is a copay between $60 and $100; and for Therapeutic Radiological Services, there is a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Prominence Giveback $75 (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Prominence Giveback $75 (HMO) plan. Although the plan covers Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, none of these specific services are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Prominence Giveback $75 (HMO) plan, but require prior authorization. For days 1-20, there is a $10 copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered for SNF, and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Prominence Giveback $75 (HMO) plan does not cover acupuncture, over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services. The plan does cover a Meal Benefit that requires prior authorization.
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