A non-government entity
Devoted GIVEBACK Arizona (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted GIVEBACK Arizona (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted GIVEBACK Arizona (HMO) in 2025, please refer to our full plan details page.
Devoted GIVEBACK Arizona (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Maricopa and Pinal Counties. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Devoted GIVEBACK Arizona (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 Arizona (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 Arizona (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 $162.60. 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 $9350.00 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:
Sign up for Devoted GIVEBACK Arizona (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Devoted GIVEBACK Arizona (HMO) plan has a $590 deductible for prescription drugs. After the deductible is met, you will pay either a copay or coinsurance depending on the drug tier and the pharmacy you use. For preferred generic drugs, you will pay a $5 copay at standard and mail order pharmacies. Standard generic drugs, preferred brand drugs, and non-preferred drugs have a 25% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Devoted GIVEBACK Arizona (HMO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services have copays depending on the specific service. Emergency services, including worldwide coverage, have copays, and ambulance services have copays or coinsurance. The plan covers primary care visits with no copay, and offers additional benefits for hearing, vision, and dental services with copays or maximum annual benefits. Home health and skilled nursing facility services are covered with no copay for some days, while other services like home infusion and dialysis have coinsurance.
Inpatient Hospital See details
Inpatient Hospital coverage with Devoted GIVEBACK Arizona (HMO) includes a $445 copay for days 1-4, and no copay for days 5-90. Additional days and non-Medicare-covered stays for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered. Outpatient hospital services have a copay between $0 and $545, and observation services have a $495 copay. Ambulatory Surgical Center (ASC) Services have no copay, and outpatient substance abuse services have a $45 copay for both individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted GIVEBACK Arizona (HMO) plan with a $70 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted GIVEBACK Arizona (HMO) plan. Ground ambulance services have a copay between $0 and $395, while air ambulance services have a 20% coinsurance; transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services under the Devoted GIVEBACK Arizona (HMO) plan includes a $110 copay, and no coinsurance. Urgently Needed Services have a copay between $0 and $45, and no coinsurance. Worldwide Emergency Services has a $110 copay for Worldwide Emergency Coverage and Worldwide Urgent Coverage, and a $395 copay with 20% coinsurance for Worldwide Emergency Transportation.
Primary Care See details
The Devoted GIVEBACK Arizona (HMO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, and specialist visits with a $55 copay. Mental health and psychiatric individual and group sessions have a $45 copay, physical therapy and speech-language pathology services have a $50 copay, and opioid treatment program services have a $45 copay. Additional telehealth benefits are covered with a copay between $0 and $55. Podiatry services are not covered.
Preventive Services See details
The Devoted GIVEBACK Arizona (HMO) plan covers a variety of preventive services, including health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit. However, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission 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, 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 include routine hearing exams with a $55 copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $599 and $899, while prescription hearing aids - inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a $20 copay, as well as coverage for eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Eyewear has a combined maximum benefit of $250 per year.
Dental Services See details
The Devoted GIVEBACK Arizona (HMO) plan covers dental services, including a $55 copay for Medicare dental services, and covers oral exams, dental x-rays, and other diagnostic dental services with no copay. This plan also offers a $250 annual maximum benefit for other dental services, and covers orthodontics under diagnostic and preventive dental. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B Insulin Drugs, you will pay a $35 copay and 20% coinsurance, while for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, you may pay between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Devoted GIVEBACK Arizona (HMO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. Durable Medical Equipment has a 17% coinsurance and requires prior authorization, while Prosthetic Devices have a 0-20% coinsurance, and Medical Supplies have a 15% coinsurance. Some services are not covered, including Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests have a copay of $0 to $95, while Lab Services have no copay. Diagnostic Radiological Services have a copay of up to $295, Therapeutic Radiological Services have 20% coinsurance, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted GIVEBACK Arizona (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 technically covered by the Devoted GIVEBACK Arizona (HMO) plan, but none of the specific sub-services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, are covered. There is a copay for some Cardiac and Pulmonary Rehabilitation Services, but the specific copay details are not provided.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted GIVEBACK Arizona (HMO) plan. For days 1-20 and 61-100, there is no copay, but for days 21-60, the copay is $180. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services, including acupuncture, over-the-counter items, and meal benefits, are not covered by this plan. Services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and Case Management (Long Term Care) are also not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
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.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved