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DEVOTED GIVEBACK 005 TN (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 005 TN (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED GIVEBACK 005 TN (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 005 TN (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Memphis. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 005 TN (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 005 TN (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 005 TN (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 $148.00. 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 $6700.00 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 005 TN (HMO) Medicare plan features an annual drug deductible of $605. Under this plan, Tier 1 preferred generic drugs are highly affordable with no copay for one-, two-, or three-month supplies filled through standard pharmacies or standard mail order. For Tier 2 generic medications, you will pay a low copay starting at $3.00 for a one-month supply, with standard mail order offering a reduced copay of $7.50 for a three-month supply. Higher-tier medications on this plan require coinsurance instead of a flat copay. Tier 3 preferred brand drugs carry a 22% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance for standard pharmacy and mail-order fills. These percentage-based costs apply to one-, two-, and three-month supplies, except for specialty drugs which are limited to a one-month supply.
Additional Benefits
The DEVOTED GIVEBACK 005 TN (HMO) plan offers affordable healthcare coverage with no copay for primary care visits, preventive services, and home health care. For hospital stays, members pay a $375 daily copay for the first 5 days of inpatient care, followed by no copay for days 6 through 90, while skilled nursing facility stays feature no copay for the first 20 days. Outpatient hospital services range from no copay to a $475 copay, and emergency room visits require a $130 copay, which is waived if you are admitted. Specialist visits and mental health services require a $45 to $50 copay, while routine dental and eyewear benefits are covered with no copay up to specified annual limits. Hearing aids are partially covered with copays ranging from $599 to $899, and routine hearing exams carry a $45 copay. Additionally, durable medical equipment and dialysis services generally require a 20% coinsurance, and Medicare Part B drugs carry up to a 20% coinsurance with a $35 copay for insulin.
Inpatient Hospital See details
DEVOTED GIVEBACK 005 TN (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance and a $375 daily copay for days 1 through 5, followed by no copay for days 6 through 90. Prior authorization is required, and while unlimited additional days are covered for acute care, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED GIVEBACK 005 TN (HMO) covers outpatient services with no coinsurance, including no copay for ambulatory surgical center and blood services. Outpatient hospital services require a copay of $0 to $475, observation services cost a $375 copay per stay, and outpatient substance abuse sessions have a $45 copay.
Partial Hospitalization See details
DEVOTED GIVEBACK 005 TN (HMO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to receive these covered services.
Ambulance and Transportation Services See details
DEVOTED GIVEBACK 005 TN (HMO) covers ambulance services with prior authorization, offering ground ambulance services with no copay to a $300 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Transportation services to health-related locations are not covered.
Emergency Services See details
DEVOTED GIVEBACK 005 TN (HMO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no coinsurance and a copay ranging from no copay to $45, while worldwide emergency services are covered up to $25,000 with a $130 copay and no coinsurance for care, and a $300 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 005 TN (HMO) covers primary care physician services with no copay and no coinsurance, while specialists, mental health, and therapy services require a $45 to $50 copay and no coinsurance. Telehealth benefits are available with no copay to a $45 copay and no coinsurance, but podiatry and chiropractic services are not covered.
Preventive Services See details
DEVOTED GIVEBACK 005 TN (HMO) covers preventive services, including annual physical exams, kidney disease education, and diabetes self-management training, with no copay and no coinsurance. Additional preventive benefits are partially covered with no copay and no coinsurance, including fitness and nutritional programs, whereas services like in-home support, therapeutic massage, and personal emergency response systems are not covered.
Hearing Services See details
DEVOTED GIVEBACK 005 TN (HMO) covers routine hearing exams with a $45 copay and no coinsurance, as well as unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $599 to $899 for up to two devices per year, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
DEVOTED GIVEBACK 005 TN (HMO) partially covers eye exams, offering one routine exam per year with a copay ranging from $0 to $45, no coinsurance, and no deductible, though other eye exam services are not covered. Eyewear is covered with no copay or coinsurance, providing a $200 annual maximum benefit toward contact lenses, eyeglasses, frames, lenses, and upgrades.
Dental Services See details
DEVOTED GIVEBACK 005 TN (HMO) dental services are partially covered, featuring a $45 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for other preventive and comprehensive services up to a $250 yearly maximum. However, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by DEVOTED GIVEBACK 005 TN (HMO) with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy, radiation, and insulin, have coinsurance ranging from no coinsurance up to 20%, with insulin requiring a $35 copay and other Part B drugs having no copay.
Dialysis Services See details
Dialysis Services are covered by DEVOTED GIVEBACK 005 TN (HMO) with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED GIVEBACK 005 TN (HMO) covers medical equipment with no copays, though prior authorization is required and coinsurance costs apply. Durable medical equipment carries 20% to 50% coinsurance, prosthetics and medical supplies range from no coinsurance to 20% coinsurance, and diabetic equipment is partially covered with no coinsurance to 50% coinsurance for supplies, though therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 005 TN (HMO) covers diagnostic and radiological services with prior authorization required, featuring no coinsurance for diagnostic services, no copay for lab services, and diagnostic test copays from $0 to $95. Radiological services require coinsurance with no copay for X-rays, copays starting at $0 for diagnostic radiology, and both copays and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered under the DEVOTED GIVEBACK 005 TN (HMO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED GIVEBACK 005 TN (HMO) with no coinsurance and require prior authorization. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 005 TN (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior 3-day hospital stay is not required, and additional days beyond the standard 100 days are not covered.
Other Services See details
Other services are partially covered by DEVOTED GIVEBACK 005 TN (HMO), which provides additional preventive services not covered by Medicare with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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