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DEVOTED GIVEBACK 021 TX (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 021 TX (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED GIVEBACK 021 TX (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 021 TX (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in San Antonio. This plan received an overall rating of 5 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 021 TX (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 021 TX (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 021 TX (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 $184.70. 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 $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 $9250.00 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 021 TX (HMO) Medicare plan features an annual prescription drug deductible of $605. For Tier 1 preferred generic drugs, members pay no copay for one, two, or three-month supplies filled at standard pharmacies or through standard mail order. Tier 2 generic drugs require a low $3 copay for a one-month supply at standard pharmacies and mail order, with slightly higher copays for two and three-month supplies. Higher tier medications are covered under a coinsurance model for standard fills. Tier 3 preferred brand drugs require a 21% coinsurance, while Tier 4 non-preferred drugs require a 25% coinsurance. Tier 5 specialty drugs also carry a 25% coinsurance, which is limited to a one-month supply.
Additional Benefits
The DEVOTED GIVEBACK 021 TX (HMO) plan focuses on affordable everyday care by offering no copay for primary care visits, home health services, and key preventive care like annual physicals. Members benefit from dental coverage with no copay up to a $250 annual maximum, a $200 annual eyewear allowance with no copay, and routine hearing exams for a $45 copay. Specialist visits require a $45 copay, ensuring predictable costs for routine medical consultations. For more intensive care, inpatient hospital stays carry a $425 daily copay for the first four days followed by no copay, while skilled nursing facility stays feature no copay for the first 20 days. Emergency room visits require a $115 copay, which is waived upon admission, and diagnostic lab services are available with no copay. Additionally, the plan includes an over-the-counter allowance of up to $200 every three months with no copay.
Inpatient Hospital See details
DEVOTED GIVEBACK 021 TX (HMO) inpatient hospital benefits are partially covered with no coinsurance, requiring a $425 daily copay for days 1 through 4 and no copay for days 5 through 90. Upgrades, non-Medicare-covered stays, and additional psychiatric hospital days are not covered.
Outpatient Services See details
Outpatient services covered by DEVOTED GIVEBACK 021 TX (HMO) feature no coinsurance, with no copays for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $525, observation services carry a $425 copay per stay, and outpatient substance abuse sessions have a $45 copay.
Partial Hospitalization See details
DEVOTED GIVEBACK 021 TX (HMO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by DEVOTED GIVEBACK 021 TX (HMO), featuring a copay ranging from no copay to $350 for ground ambulance services and a 20% coinsurance for air ambulance services, with prior authorization required. Some transportation services are covered, but transportation to plan-approved health-related locations and any health-related locations are not covered.
Emergency Services See details
DEVOTED GIVEBACK 021 TX (HMO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services feature a copay ranging from no copay to $40 with no coinsurance, and worldwide emergency services are covered up to $25,000 with a $115 copay and no coinsurance for emergency or urgent care, and a $350 copay with 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED GIVEBACK 021 TX (HMO) provides primary care physician services with no copay and no coinsurance, and specialist visits with a $45 copay and no coinsurance. Additional covered benefits include physical therapy, occupational therapy, and mental health services with copays ranging from $35 to $50 and no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive Services are covered by DEVOTED GIVEBACK 021 TX (HMO) with no copay and no coinsurance for annual physicals, kidney disease education, and diabetes training. Additional preventive services are partially covered with no copay and no coinsurance; however, in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, therapeutic massage, adult day health, home palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access, and counseling are not covered.
Hearing Services See details
Hearing services covered by DEVOTED GIVEBACK 021 TX (HMO) include routine exams with a $45 copay, no coinsurance, and no deductible, and prescription hearing aids with a $599 to $899 copay and no coinsurance. This benefit is partially covered, as OTC hearing aids and inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision Services are partially covered by DEVOTED GIVEBACK 021 TX (HMO), as other eye exam services are not covered. Covered eye exams have a $0 to $45 copay and no coinsurance, while eyewear is covered with no copay and no coinsurance up to a $200 annual maximum with no deductible.
Dental Services See details
Dental services are partially covered by DEVOTED GIVEBACK 021 TX (HMO), featuring a $45 copay and no coinsurance for Medicare-covered dental services, and no copay or coinsurance for other covered dental services up to a $250 annual maximum. While preventive and most comprehensive services are covered with no copay and no coinsurance, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by DEVOTED GIVEBACK 021 TX (HMO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs have no copay and no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
DEVOTED GIVEBACK 021 TX (HMO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required to receive this covered benefit.
Medical Equipment See details
Medical equipment is partially covered under the DEVOTED GIVEBACK 021 TX (HMO) plan with no copays, though prior authorization is required for most items. Durable medical equipment carries a 15% coinsurance, while covered prosthetics, medical supplies, and diabetic supplies range from no coinsurance up to 15% or 20% coinsurance; however, diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 021 TX (HMO) covers diagnostic services with no coinsurance, offering lab services with no copay and diagnostic procedures with a copay of $0 to $95. Radiological services require prior authorization and feature outpatient X-rays with no copay, diagnostic radiology with a copay starting at $0, and therapeutic radiology with a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED GIVEBACK 021 TX (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
DEVOTED GIVEBACK 021 TX (HMO) covers cardiac rehabilitation services with no coinsurance and prior authorization required, though some services are covered while standard cardiac rehabilitation ($30 copay), intensive cardiac rehabilitation ($30 copay), pulmonary rehabilitation ($25 copay), and SET for PAD services ($20 copay) are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 021 TX (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED GIVEBACK 021 TX (HMO) partially covers other services, providing over-the-counter items (up to $200 every three months) and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and other supplementary services are not covered under this plan.
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