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DEVOTED GIVEBACK 002 NM (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED GIVEBACK 002 NM (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED GIVEBACK 002 NM (HMO) in 2026, please refer to our full plan details page.
DEVOTED GIVEBACK 002 NM (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Central and Northern New Mexico. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED GIVEBACK 002 NM (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 002 NM (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 002 NM (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 $7000.00 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 002 NM (HMO) plan features an annual drug deductible of $605. For Tier 1 preferred generic drugs, members enjoy no copay for one, two, or three-month supplies at standard pharmacies and through standard mail order. Tier 2 generic drugs are also highly affordable, with a copay of just $3.00 for a one-month supply at standard pharmacies and standard mail order. For higher-tier medications, costs are based on a percentage of the drug's price rather than a flat copay. Tier 3 preferred brand drugs require a 21% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance. These cost-sharing rates apply to both standard pharmacy purchases and standard mail-order services.
Additional Benefits
The DEVOTED GIVEBACK 002 NM (HMO) plan offers robust medical coverage featuring no copay and no coinsurance for primary care doctor visits, home health services, and routine preventive care. For specialist visits, patients will pay a $55 copay, while inpatient hospital stays require a $475 daily copay for the first three days and no copay for days 4 through 90. Emergency room visits carry a $115 copay, which is waived if you are admitted, and ground ambulance services range from no copay up to a $315 copay. Ancillary benefits include routine vision and dental care with no copay up to annual maximums of $200 and $250 respectively, alongside routine hearing exams for a $55 copay. Diagnostic services like lab tests and X-rays feature no copay, while durable medical equipment requires a 17% coinsurance and Part B insulin features a $35 copay. Additionally, the plan provides an over-the-counter allowance of up to $94 every three months with no copay or coinsurance.
Inpatient Hospital See details
DEVOTED GIVEBACK 002 NM (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, featuring a $475 daily copay for days 1 through 3 and no copay for days 4 through 90. Unlimited additional days are covered for acute care, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED GIVEBACK 002 NM (HMO) covers outpatient services with no coinsurance, including no copay for ambulatory surgical center and blood services. Outpatient substance abuse sessions require a $50 copay, while outpatient hospital and observation services carry copays ranging from $0 to $575, with prior authorization required.
Partial Hospitalization See details
DEVOTED GIVEBACK 002 NM (HMO) covers partial hospitalization services with an $80 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
DEVOTED GIVEBACK 002 NM (HMO) covers ambulance services with prior authorization, requiring no copay to a $315 copay (with no coinsurance) for ground services and a 20% coinsurance (with no copay) for air services. While some transportation services are covered, trips to plan-approved or any health-related locations are not covered.
Emergency Services See details
DEVOTED GIVEBACK 002 NM (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 require no copay to a $40 copay and no coinsurance, while worldwide emergency services are covered up to $25,000 with copays ranging from $115 to $315 and 20% coinsurance for emergency transportation.
Primary Care See details
Primary care benefits under DEVOTED GIVEBACK 002 NM (HMO) feature no copay and no coinsurance for primary care doctor visits, while specialist visits require a $55 copay and no coinsurance. Physical, occupational, and mental health therapies require copays ranging from $35 to $55 and no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
DEVOTED GIVEBACK 002 NM (HMO) offers preventive services with no copay and no coinsurance for covered benefits like annual physical exams, fitness benefits, and kidney disease education. Because this benefit is only partially covered, several services are not covered, including in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, in-home support services, and counseling.
Hearing Services See details
DEVOTED GIVEBACK 002 NM (HMO) provides hearing services with no deductible, including routine hearing exams for a $55 copay and no coinsurance, and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $599 to $899, but OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
DEVOTED GIVEBACK 002 NM (HMO) provides partially covered vision services, which include eye exams with a $0 to $55 copay and no coinsurance, though other eye exam services are not covered. Covered eyewear options, including contacts, eyeglasses, lenses, frames, and upgrades, have no copay or coinsurance up to a $200 annual maximum.
Dental Services See details
DEVOTED GIVEBACK 002 NM (HMO) offers partially covered dental services, with Medicare-covered dental requiring a $55.00 copay and no coinsurance, and other covered dental services having no copay and no coinsurance up to a $250.00 annual maximum. While preventive, diagnostic, and restorative services are covered, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED GIVEBACK 002 NM (HMO) with no copay, though prior authorization is required. Under this benefit, chemotherapy, radiation, and other Part B drugs carry no copay and coinsurance ranging from no coinsurance to 20%, while Part B insulin requires a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered by DEVOTED GIVEBACK 002 NM (HMO) with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
DEVOTED GIVEBACK 002 NM (HMO) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment (DME) carries a 17% coinsurance, while prosthetic devices and medical supplies range from no coinsurance to 20% coinsurance. Diabetic equipment is partially covered, with diabetic supplies requiring no coinsurance to 17% coinsurance, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED GIVEBACK 002 NM (HMO) covers diagnostic and radiological services, with prior authorization required for these benefits. Outpatient lab services, X-rays, and diagnostic radiological services are offered with no copays, while diagnostic procedures and tests range from no copay to a $95 copay with no coinsurance, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the DEVOTED GIVEBACK 002 NM (HMO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are not covered under the DEVOTED GIVEBACK 002 NM (HMO) plan. This includes cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) rehabilitation services, which are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
DEVOTED GIVEBACK 002 NM (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 and a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
DEVOTED GIVEBACK 002 NM (HMO) partially covers other services, providing additional preventive services and over-the-counter (OTC) items with no copay and no coinsurance, up to a $94 limit every three months. Acupuncture, meal benefits, and certain other services are not covered under this plan.
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