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Devoted GIVEBACK Tennessee (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted GIVEBACK Tennessee (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted GIVEBACK Tennessee (HMO) in 2025, please refer to our full plan details page.
Devoted GIVEBACK Tennessee (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 4 out of 5 stars in 2025.
It's important to know that Devoted GIVEBACK Tennessee (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 Tennessee (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 Tennessee (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 $147.60. 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 $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 Tennessee (HMO) plan has an "Enhanced Alternative" drug benefit. The plan has a $590 deductible. In the initial coverage phase, after the deductible is met, you'll pay a $7 copay for preferred generic drugs at standard and mail-order pharmacies. For standard generic, preferred brand, and non-preferred drugs, you'll pay 25% coinsurance. After your yearly out-of-pocket drug costs reach $2000, you pay nothing for covered drugs.
Additional Benefits
The Devoted GIVEBACK Tennessee (HMO) plan offers comprehensive coverage with varying costs for different services. Inpatient hospital stays have a copay, while outpatient services, including some mental health services, have copays ranging from $0 to $475. Emergency services, including worldwide emergency services, are covered with a copay and/or coinsurance. The plan also includes benefits for primary care, preventive services, hearing, vision, dental, and home health services, with specific copays or coinsurance amounts. Additional benefits include coverage for ambulance, partial hospitalization, medical equipment, and skilled nursing facilities, with specific cost-sharing requirements. However, the plan does not cover some other services, such as acupuncture and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered, but require prior authorization. For Inpatient Hospital-Acute, you will pay a $375 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you will pay a $375 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered, while Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered. Additional days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital Services have a copay between $0 and $475, Observation Services have a $375 copay, and ASC Services have no copay. Individual and group sessions for outpatient substance abuse services have a copay of $45.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted GIVEBACK Tennessee (HMO) plan with a $70 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a copay between $0 and $300, and air ambulance services have a 20% coinsurance, while transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Devoted GIVEBACK Tennessee (HMO) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a copay of $0-$55. Worldwide Emergency Transportation has a $300 copay and 20% coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 copay.
Primary Care See details
Under the Devoted GIVEBACK Tennessee (HMO) plan, primary care physician services and chiropractic services are covered with a $20 copay, while occupational therapy services, physician specialist services, individual and group sessions for mental health specialty services, individual and group sessions for psychiatric services, and opioid treatment program services have a $45 copay. Physical therapy and speech-language pathology services cost between $45 and $50, and additional telehealth benefits have a copay between $0 and $45.
Preventive Services See details
The Devoted GIVEBACK Tennessee (HMO) plan covers preventive services, including annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit. The plan does not cover in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, readmission prevention, wigs for hair loss related to chemotherapy, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, or counseling services.
Hearing Services See details
Hearing exams are covered with a $45 copay, and routine hearing exams are limited to one visit per year. Fitting/Evaluation for Hearing Aids are covered. Prescription Hearing Aids (all types) are covered with a copay between $599 and $899 for two hearing aids per year. Prescription hearing aids - Inner Ear, Outer Ear, and Over the Ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
The Devoted GIVEBACK Tennessee (HMO) plan covers vision services, including routine eye exams with a $45 copay, and eyewear with a combined maximum benefit of $250 every year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The Devoted GIVEBACK Tennessee (HMO) plan covers Medicare Dental Services with a $45 copay, and other dental services including oral exams, dental x-rays, and more. This plan has a $250 maximum benefit per year for other dental services, and does not cover maxillofacial prosthetics, implant services, or orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with a $35 copay for Medicare Part B Insulin Drugs, and a coinsurance between 0% and 20% for Medicare Part B Chemotherapy/Radiation Drugs, Other Medicare Part B Drugs, and Medicare Part B Insulin Drugs. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Devoted GIVEBACK Tennessee (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% to 30% coinsurance, Prosthetic Devices with a 0% to 20% coinsurance, and Medical Supplies with a 20% coinsurance; however, Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a copay between $0 and $95, and Lab Services with no copay. Radiological Services include a copay for diagnostic and therapeutic services, and a 20% coinsurance for therapeutic services.
Home Health Services See details
Home Health Services are covered by the Devoted GIVEBACK Tennessee (HMO) plan, with no copay or coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. The copay for these services is listed in the plan details.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by Devoted GIVEBACK Tennessee (HMO). For days 1-20, there is no 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
Other Services are not covered by the Devoted GIVEBACK Tennessee (HMO) plan. Some services that are not covered include Acupuncture, Over-the-Counter (OTC) Items, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and more.
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