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DEVOTED GIVEBACK 019 AZ (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 019 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 019 AZ (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 019 AZ (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 3.5 out of 5 stars in 2026.
It's important to know that DEVOTED GIVEBACK 019 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 019 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 019 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 019 AZ (HMO) Medicare plan offers an Enhanced Alternative drug benefit with a $605.00 prescription drug deductible. After meeting this deductible, you will enter the initial coverage phase where Tier 1 preferred generics cost a $3.00 copay at standard pharmacies and through standard mail. For other tiers, you will pay a coinsurance of 22% for Tier 2 standard generics, and 25% for Tier 3 preferred brands and Tier 4 non-preferred drugs. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay no copay for Medicare Part D covered drugs. Additionally, if you qualify for Extra Help or the Low-Income Subsidy, your Part D premium is reduced to no cost. Be sure to check the plan's formulary to verify coverage for your specific medications.
Additional Benefits
The DEVOTED GIVEBACK 019 AZ (HMO) plan offers essential medical coverage with clear cost-sharing, including inpatient hospital stays at a $495 daily copay for days 1 through 4 and no copay for days 5 through 90. Outpatient hospital services range from no copay to a $595 copay, while ambulatory surgical center visits require no copay. Emergency room visits have a $115 copay that is waived if admitted, and urgent care options range from no copay to a $40 copay. Routine care includes preventive services and annual physicals with no copay, while primary care visits range from no copay to a $55 copay. Vision exams have a copay up to $55 with no copay for eyewear up to a $400 annual maximum, and dental and hearing exams both require a $55 copay. Additionally, members benefit from a $140 over-the-counter allowance every three months and skilled nursing facility care with no copay for the first 20 days.
Inpatient Hospital See details
Inpatient hospital services are covered by DEVOTED GIVEBACK 019 AZ (HMO) with a $495 daily copay for days 1 through 4, no copay for days 5 through 90, and no coinsurance. While unlimited additional acute care days are covered, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED GIVEBACK 019 AZ (HMO) covers outpatient services with no coinsurance, offering ambulatory surgical center services with no copay and outpatient hospital services with a copay ranging from $0 to $595. Additionally, patients pay a $495 copay per stay for observation services, a $50 copay for outpatient substance abuse sessions, and no copay or deductible for outpatient blood services.
Partial Hospitalization See details
Partial hospitalization is covered under the DEVOTED GIVEBACK 019 AZ (HMO) plan with a $70.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
DEVOTED GIVEBACK 019 AZ (HMO) covers ground ambulance services with a copay of $0 to $395 and air ambulance services with a 20% coinsurance, both requiring prior authorization. While some transportation services are covered, transportation to plan-approved health-related locations and any health-related locations are not covered in practice.
Emergency Services See details
DEVOTED GIVEBACK 019 AZ (HMO) covers emergency services with a $115 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgent care with no copay to a $40 copay and no coinsurance. Worldwide emergency services are covered up to a $25,000 maximum, requiring a $115 copay and no coinsurance for emergency or urgent care, and a $395 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
Primary care benefits are partially covered under the DEVOTED GIVEBACK 019 AZ (HMO) plan, with podiatry services and routine chiropractic care not covered. Covered services require no coinsurance, with copays ranging from no copay up to $55 depending on the service.
Preventive Services See details
DEVOTED GIVEBACK 019 AZ (HMO) partially covers preventive services, offering covered services like annual physical exams and fitness benefits with no copay and no coinsurance. However, sub-services such as in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation, disease management, telemonitoring, remote access, and counseling are not covered.
Hearing Services See details
DEVOTED GIVEBACK 019 AZ (HMO) partially covers hearing services, featuring a $55 copay and no coinsurance or deductible for routine exams, and a $399 to $699 copay with no coinsurance for prescription hearing aids. OTC hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
DEVOTED GIVEBACK 019 AZ (HMO) covers vision services, featuring eye exams with a copay ranging from no copay up to $55 and no coinsurance. Eyewear, including contacts and eyeglasses, is covered with no copay, no coinsurance, and a combined annual maximum benefit of $400.
Dental Services See details
Dental services are partially covered by DEVOTED GIVEBACK 019 AZ (HMO), excluding maxillofacial prosthetics, implant services, and orthodontics. Medicare-covered dental services require a $55 copay and no coinsurance, while other covered dental services are subject to an annual maximum plan benefit of $250.
Home Infusion bundled Services See details
DEVOTED GIVEBACK 019 AZ (HMO) covers Home Infusion bundled Services, subject to prior authorization. Medicare Part B insulin drugs require a $35 copay and 0% to 20% coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by DEVOTED GIVEBACK 019 AZ (HMO) with a 20% coinsurance and no copay. Prior authorization is required to receive these covered services.
Medical Equipment See details
Medical Equipment is partially covered by DEVOTED GIVEBACK 019 AZ (HMO), as diabetic therapeutic shoes and inserts are not covered. Covered durable medical equipment, prosthetics, and medical supplies require no copay, with coinsurance ranging from no coinsurance to 20%.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 019 AZ (HMO) covers diagnostic and radiological services with prior authorization, offering no copay for lab services and outpatient X-rays. Diagnostic procedures and tests range from no copay up to a $95 copay, diagnostic radiological services range from no copay up to a $295 copay, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home health services are covered under the DEVOTED GIVEBACK 019 AZ (HMO) plan, though prior authorization is required before you can receive care.
Cardiac Rehabilitation Services See details
DEVOTED GIVEBACK 019 AZ (HMO) does not cover Cardiac Rehabilitation Services, as none of the sub-services—including intensive cardiac, pulmonary, and SET for PAD rehabilitation—are covered in practice.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by DEVOTED GIVEBACK 019 AZ (HMO) with no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, with no coinsurance. Prior authorization is required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by DEVOTED GIVEBACK 019 AZ (HMO), featuring a $140 over-the-counter allowance every three months and coverage for additional preventive services. Acupuncture, meal benefits, and dual-eligible SNP services are not covered, and copay or coinsurance details are not specified for the covered benefits.
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