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Prominence Giveback $100 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Prominence Giveback $100 (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Prominence Giveback $100 (HMO) in 2025, please refer to our full plan details page.
Prominence Giveback $100 (HMO) is a HMO plan offered by Universal Health Services, Inc. available for enrollment in 2025 to people living in North Texas. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Prominence Giveback $100 (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 $100 (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 $100 (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 $100.00. 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 $375.00 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 $6200.00 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 $100 (HMO) plan has a $375.00 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier. For example, in the initial coverage phase, you will pay a $15 copay for preferred generic drugs at a standard pharmacy, and a $100 copay for preferred brand drugs. For non-preferred drugs, you will pay 28% coinsurance. Specialty tier drugs have no copay. After your yearly out-of-pocket drug costs reach $2000.00, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Prominence Giveback $100 (HMO) plan offers a range of benefits, including inpatient hospital stays with copays, and outpatient services like primary care and substance abuse treatment with varying copays. The plan also covers preventive services, such as annual physical exams, with no copay. Additional benefits include hearing, vision, and dental services, with annual maximums and copays for specific services. The plan also covers home health services with no copay, and skilled nursing facility stays with copays.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a copay of $255 for days 1-6 and no copay for days 7-90 for Inpatient Hospital-Acute. Inpatient Hospital Psychiatric has a copay of $330 for days 1-5 and no copay for days 6-60.
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 $25 copay, and both individual and group outpatient substance abuse sessions have a $30 copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Prominence Giveback $100 (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 $100 (HMO) plan. Ground and Air Ambulance Services have a $325 copay, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Prominence Giveback $100 (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, Urgently Needed Services has a $20 copay, and Worldwide Urgent Coverage has a $30 copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Prominence Giveback $100 (HMO) plan covers primary care physician services, occupational therapy services, mental health specialty services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $20 copay, physician specialist services have a $45 copay, individual and group sessions for mental health and psychiatric services have a $30 copay, physical therapy and speech-language pathology services have a $10 copay, and opioid treatment program services have a $10 copay.
Preventive Services See details
The Prominence Giveback $100 (HMO) plan covers preventive services, including annual physical exams, with no copay. Additionally, the plan covers in-home safety assessments, telemonitoring services, remote access technologies, fitness benefits, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit, all with no copay. However, health education, personal emergency response systems, medical nutrition therapy, 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 benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $10 copay, and routine hearing exams and fitting/evaluation for hearing aids are covered annually. Prescription hearing aids (all types) are covered, with a maximum copay of $1725, and a maximum plan benefit of $600 per ear every year, however, some services are not covered: Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $30 copay, and eyewear including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Eyewear has a combined maximum plan benefit coverage of $200 every year.
Dental Services See details
The Prominence Giveback $100 (HMO) plan covers dental services with a maximum benefit of $1,000 per year. Oral exams, dental x-rays, and other diagnostic dental services are covered, with limits on the number of visits, and Restorative Services, Endodontics, Periodontics, Prosthodontics, fixed, Oral and Maxillofacial Surgery have copays ranging from $0 to $100.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. 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 $100 (HMO) plan, with a coinsurance between 20% and 20%. Prior authorization is required.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetic Devices, and Medical Supplies, also with a 20% coinsurance. Diabetic Therapeutic Shoes/Inserts are covered with a 20% coinsurance, but Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
The Prominence Giveback $100 (HMO) plan covers diagnostic and radiological services, but Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered. Diagnostic Radiological Services have a copay of at most $125, while Therapeutic Radiological Services have a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Prominence Giveback $100 (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Prominence Giveback $100 (HMO) plan. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Prominence Giveback $100 (HMO) plan, with prior authorization required. You will have a copay of $10 for days 1-20, and a copay of $214 for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include a meal benefit that is covered, but requires prior authorization. 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 are not covered.
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