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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 Nashville. 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 $122.70. 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 $8500.00 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 a $590 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you will pay a $10 copay at standard and mail order pharmacies. Standard generic drugs, preferred brand drugs, and non-preferred drugs will cost 25% coinsurance at standard and mail order pharmacies.
Additional Benefits
The Devoted GIVEBACK Tennessee (HMO) plan offers a wide range of benefits, including coverage for inpatient and outpatient services, with varying copays depending on the service. The plan also covers primary care, preventive services, and specialized services like hearing, vision, and dental, each with specific copayments and limitations. Additionally, this plan provides coverage for ambulance, emergency, and home health services, as well as medical equipment and diagnostic services. This plan includes benefits like home infusion, dialysis, and skilled nursing facility care, with different cost-sharing structures. However, it's important to note that certain services such as cardiac rehabilitation, additional home health hours, and other services like acupuncture and over-the-counter items are not covered. Be sure to review the details for specific copays, coinsurance, and any prior authorization requirements.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization. For Inpatient Hospital-Acute, you will pay a $425 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you will pay a $425 copay for days 1-4, and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, observation services, and outpatient substance abuse services, are covered. Outpatient hospital services have a copay between $0 and $525, observation services have a $425 copay, individual and group sessions for outpatient substance abuse have a $45 copay. Ambulatory Surgical Center (ASC) Services have no copay, and outpatient blood services are covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted GIVEBACK Tennessee (HMO) plan, and requires prior authorization. You will pay a $65 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted GIVEBACK Tennessee (HMO) plan. Ground ambulance services have a copay between $0 and $300, and air ambulance services have a 20% coinsurance; however, 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 $110 copay, while Urgently Needed Services have a copay between $0 and $45; Worldwide Emergency Transportation has a 20% coinsurance and a $300 copay, and Worldwide Emergency Coverage, and Worldwide Urgent Coverage each have a $110 copay.
Primary Care See details
Primary Care, including Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy, Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services, are covered. Chiropractic Services have a $15 copay, Physician Specialist Services and Physical Therapy have a $50 copay, Occupational Therapy Services have a $35 copay, and Mental Health Specialty Services, Psychiatric Services, and Opioid Treatment Program Services have a $45 copay. Routine Chiropractic Care and Podiatry Services are not covered. Additional Telehealth Benefits have a copay between $0 and $50.
Preventive Services See details
The Devoted GIVEBACK Tennessee (HMO) plan covers preventive services, including an annual physical exam, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and an EKG following a welcome visit. However, 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, and counseling services are not covered.
Hearing Services See details
Hearing Services includes routine hearing exams with a $50 copay for one visit per year, as well as fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a copay between $599 and $899 for two visits per year, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. Over-the-counter hearing aids are not covered.
Vision Services See details
Vision services are covered, including routine eye exams with a $50 copay. Eyewear is covered, with a combined maximum plan benefit of $250 every year for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
The Devoted GIVEBACK Tennessee (HMO) plan covers Medicare Dental Services with a $50 copay, other dental services, oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. The plan does not cover maxillofacial prosthetics, implant services, or orthodontics, and has a $250 annual maximum for other dental services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under 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 coinsurance of 0-20% and no copay, Prosthetics/Medical Supplies with no copay and coinsurance for Medicare-covered items, and Diabetic Equipment. 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 and tests with a copay between $0 and $95, lab services with no copay, and outpatient X-ray services with no copay. Diagnostic radiological services have a copay of at most $300, while therapeutic radiological services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Devoted GIVEBACK Tennessee (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 Devoted GIVEBACK Tennessee (HMO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered under the Devoted GIVEBACK Tennessee (HMO) plan, with prior authorization required. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services are not covered, including acupuncture, over-the-counter items, meal benefits, 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. Other 2 services are covered.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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