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DEVOTED GIVEBACK 013 AZ (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 013 AZ (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED GIVEBACK 013 AZ (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 013 AZ (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Pima County. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 013 AZ (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 013 AZ (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 013 AZ (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 $7900.00 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 013 AZ (HMO) plan features an Enhanced Alternative drug benefit with a prescription drug deductible of $605.00. After meeting this deductible, you enter the initial coverage phase where Tier 1 preferred generic drugs require a $3.00 copay at standard pharmacies and standard mail orders. For higher tiers, you will pay a 22% coinsurance for standard generics and a 25% coinsurance for preferred brands and non-preferred drugs. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for Medicare Part D covered drugs. Additionally, if you qualify for the low-income subsidy, your Part D premium is reduced to no copay.
Additional Benefits
The DEVOTED GIVEBACK 013 AZ (HMO) plan offers affordable coverage for core medical needs, featuring no copay for preventive care and primary care copays ranging from no copay up to $50. Inpatient hospital stays require a $395 copay for days 1 through 5 and no copay for days 6 through 90, while outpatient hospital services range from no copay up to a $495 copay. Emergency services are covered with a $115 copay and no coinsurance, and urgently needed care ranges from no copay to a $40 copay. For supplemental care, the plan provides routine vision exams with copays up to $45 and a $400 annual eyewear allowance with no copay, alongside dental and hearing exams that feature a $45 copay. Members also benefit from a $145 quarterly allowance for over-the-counter items and no copay for the first 20 days of skilled nursing facility stays. Diagnostic lab and X-ray services require no copay or coinsurance, while medical equipment and dialysis services generally carry a coinsurance of up to 20% with no copay.
Inpatient Hospital See details
DEVOTED GIVEBACK 013 AZ (HMO) partially covers inpatient hospital services with a $395 copay for days 1 through 5 and no copay or coinsurance for days 6 through 90. While acute and psychiatric stays are covered, upgrades, non-Medicare-covered stays, and additional days for psychiatric care are not covered.
Outpatient Services See details
Outpatient Services are covered by DEVOTED GIVEBACK 013 AZ (HMO) with no coinsurance, featuring no copay for ambulatory surgical center services and a $0 to $495 copay for outpatient hospital services. Additionally, observation services require a $395 copay per stay, outpatient substance abuse sessions have a $45 copay, and outpatient blood services are covered with no deductible.
Partial Hospitalization See details
DEVOTED GIVEBACK 013 AZ (HMO) covers partial hospitalization benefits with a $70 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
DEVOTED GIVEBACK 013 AZ (HMO) partially covers Ambulance and Transportation Services, as transportation services to plan-approved or any health-related locations are not covered. Covered ground ambulance services cost between no copay and a $370 copay plus coinsurance, while air ambulance services require a 20% coinsurance plus a copay.
Emergency Services See details
DEVOTED GIVEBACK 013 AZ (HMO) covers emergency services with a $115 copay and no coinsurance, and urgently needed services with a copay ranging from no copay to $40 and no coinsurance. Worldwide emergency services are also covered up to a $25,000 limit, with copays ranging from $115 to $370 and coinsurance up to 20%.
Primary Care See details
Primary Care benefits are partially covered by DEVOTED GIVEBACK 013 AZ (HMO), as podiatry services and routine chiropractic care are not covered. Covered services require copays ranging from no copay up to $50 depending on the service, with no coinsurance.
Preventive Services See details
Preventive services are partially covered by DEVOTED GIVEBACK 013 AZ (HMO), offering no copay or coinsurance for Medicare-covered zero-dollar preventive services and annual physical exams. While fitness and weight management programs are included, other services—including in-home safety assessments, personal emergency response systems, medical nutrition therapy, medication reconciliation, readmission prevention, wigs, therapeutic massage, adult day health, palliative care, in-home support, caregiver support, extra smoking cessation, disease management, telemonitoring, remote access, and counseling—are not covered.
Hearing Services See details
Hearing services are partially covered by DEVOTED GIVEBACK 013 AZ (HMO), which offers routine hearing exams and fitting evaluations for a $45 copay and no coinsurance. While prescription hearing aids are covered up to two per year, OTC hearing aids and prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision services are covered by DEVOTED GIVEBACK 013 AZ (HMO), offering eye exams with no coinsurance and copays ranging from no copay up to $45. The plan also includes a $400 annual allowance for eyewear, including contacts and eyeglasses, with no copay or coinsurance.
Dental Services See details
Dental services are partially covered under the DEVOTED GIVEBACK 013 AZ (HMO) plan, featuring a $45 copay and no coinsurance for Medicare-covered dental services, with a $250 annual maximum for other covered dental benefits. Implant services, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under DEVOTED GIVEBACK 013 AZ (HMO) and require prior authorization. Medicare Part B insulin drugs have a $35 copay and coinsurance ranging from no coinsurance to 20%, while chemotherapy, radiation, and other Part B drugs require no copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED GIVEBACK 013 AZ (HMO) plan with a 20% coinsurance and no copay. Prior authorization is required before receiving these services.
Medical Equipment See details
Medical Equipment benefits are partially covered by DEVOTED GIVEBACK 013 AZ (HMO), as diabetic therapeutic shoes and inserts are not covered. Other covered equipment and supplies require no copay and feature coinsurance ranging from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED GIVEBACK 013 AZ (HMO) with prior authorization. Lab and outpatient X-ray services require no copay and no coinsurance, while other diagnostic procedures and radiological services carry copays ranging from $0 to $295 with no coinsurance, except for therapeutic radiology which has a 20% coinsurance and no copay.
Home Health Services See details
Home health services are covered by the DEVOTED GIVEBACK 013 AZ (HMO) plan, though prior authorization is required to receive these benefits.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the DEVOTED GIVEBACK 013 AZ (HMO) plan, as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 013 AZ (HMO) partially 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, and additional days beyond Medicare-covered limits are not covered.
Other Services See details
Other Services are partially covered by DEVOTED GIVEBACK 013 AZ (HMO), offering a $145 quarterly allowance for over-the-counter items and additional preventive services with no copay or coinsurance. Acupuncture, meal benefits, and highly integrated dual-eligible SNP services are not covered.
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