DEVOTED GIVEBACK 001 HI (HMO)

by Devoted Health

2026 Medicare Advantage plan available in Hawaii

Plan ID H5397-001-0

Additional coverage:

RxHearingVisionDental

Medicare Advantage HMO $0 premium

Monthly plan premium $0 / mo

Annual deductible $0 / yr

Max out-of-pocket · in-network $8,300 / yr

Drug deductible $605 / yr

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Plan Overview

DEVOTED GIVEBACK 001 HI (HMO) is a Medicare Advantage Plan With Part D Prescription Drug Coverage, which is available in Hawaii and offered by the health insurance company Devoted Health. This plan's network type is HMO, which determines the in-network doctors who accept the plan and whether a referral is needed.

Plan Name DEVOTED GIVEBACK 001 HI (HMO)

Insurance Carrier Devoted Health

Plan Type Medicare Advantage Plan With Part D Prescription Drug Coverage

Network Type HMO

Cost Summary

DEVOTED GIVEBACK 001 HI (HMO) has a monthly premium cost of $0 per month, with an annual deductible of $0 and a maximum out-of-pocket cost sharing of $8,300. The most common costs people evaluate when choosing a plan are listed here; a full list of benefit costs is defined below.

Monthly Premium $0 / mo

Health portion of premium $0

Drug portion of premium $0

Annual Deductible $0 / yr

Max Out-of-Pocket · in-network $8,300 / yr

Primary doctor visit $0 copay

Specialist visit $55 copay

ER visit $115 copay

Ambulance $0-$315 copay

Additional Benefits and Coverage

DEVOTED GIVEBACK 001 HI (HMO) is a Medicare Advantage plan which includes Medicare Part D prescription drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. DEVOTED GIVEBACK 001 HI (HMO) includes coverage for hearing, vision, dental.

Part D Prescription Drug Coverage Yes

Dental Yes

Vision Yes

Hearing Yes

Nationwide Coverage No

Other benefits

Fitness benefit Limited coverage

Over-the-counter drug benefits Not covered

In-home support services Not covered

Home & bathroom safety devices Limited coverage

Meals for short duration Not covered

Annual physical exams Limited coverage

Telehealth Limited coverage

Medical Benefits

Doctor Services

Primary doctor visit In-network: $0 copay
Out-of-network: $0 copay

Specialist visit In-network: $55 copay
Out-of-network: $55 copay

Tests, labs & imaging

Diagnostic tests & procedures In-network: $0-$95 copay
Out-of-network: $0-$95 copay

Lab services In-network: $0-$40 copay
Out-of-network: $0-$40 copay

Diagnostic radiology services (like MRI) In-network: $0-$300 copay
Out-of-network: $0-$300 copay

Outpatient x-rays In-network: $0-$75 copay
Out-of-network: $0-$75 copay

Emergency care $115 copay

Urgent care $0-$40 copay

Hospital Services

Inpatient hospital coverage Tier 1
$375 per day for days 1-4
$0 per day for days 5-90
$0 per stay

Outpatient hospital coverage In-network: $0-$375 copay
Out-of-network: $0-$375 copay

Skilled nursing facility

Skilled nursing facility Tier 1
$0 per day for days 1-20
$218 per day for days 21-100

Preventive services

Preventive services In-network: $0 copay
Out-of-network: $0 copay

Ambulance

Ground ambulance In-network: $0-$315 copay
Out-of-network: $0-$315 copay

Therapy services

Occupational therapy visit In-network: $35 copay
Out-of-network: $35 copay

Physical therapy & speech & language therapy visit In-network: $55 copay
Out-of-network: $55 copay

Mental health services

Outpatient group therapy with a psychiatrist In-network: $50 copay
Out-of-network: $50 copay

Outpatient individual therapy with a psychiatrist In-network: $50 copay
Out-of-network: $50 copay

Outpatient group therapy visit In-network: $50 copay
Out-of-network: $50 copay

Outpatient individual therapy visit In-network: $50 copay
Out-of-network: $50 copay

Opioid treatment services

Opioid treatment services Covered

Other services

Durable medical equipment (like wheelchairs & oxygen) In-network: 15% coinsurance
Out-of-network: 15% coinsurance

Prosthetics (like braces, artificial limbs) In-network: 0%-15% coinsurance
Out-of-network: 0%-15% coinsurance

Diabetes supplies In-network: 0%-15% coinsurance
Out-of-network: 0%-15% coinsurance

Prescription drugs (Part D benefits)

Drug tier standard retail · 1-month supply Initial coverage Catastrophic

Preferred Generic $0.00 copay $0 copay

Generic $1.00 copay $0 copay

Preferred Brand 24% coinsurance $0 copay

Non-Preferred Drug 25% coinsurance $0 copay

Specialty Tier 25% coinsurance $0 copay

Part B drugs

Chemotherapy drugs In-network: 0%-20% coinsurance
Out-of-network: 0%-20% coinsurance

Other Part B drugs In-network: 0%-20% coinsurance
Out-of-network: 0%-20% coinsurance

Extra Benefits

Hearing

Hearing exam In-network: $0 copay
Out-of-network: $0 copay

Fitting/evaluation In-network: $0 copay
Out-of-network: $0 copay

Hearing aids - prescription In-network: $599-$899 copay
Out-of-network: $599-$899 copay

Hearing aids - over the counter Not covered

Preventive dental

Oral exam In-network: $0 copay
Out-of-network: $0 copay

Cleaning In-network: $0 copay
Out-of-network: $0 copay

Fluoride treatment In-network: $0 copay
Out-of-network: $0 copay

Dental x-rays In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Restorative services In-network: $0 copay
Out-of-network: $0 copay

Endodontics In-network: $0 copay
Out-of-network: $0 copay

Periodontics In-network: $0 copay
Out-of-network: $0 copay

Prosthodontics, removable In-network: $0 copay
Out-of-network: $0 copay

Prosthodontics, fixed In-network: $0 copay
Out-of-network: $0 copay

Maxillofacial prosthetics Not covered

Implant services Not covered

Oral and maxillofacial surgery In-network: $0 copay
Out-of-network: $0 copay

Orthodontics Not covered

Adjunctive general services In-network: $0 copay
Out-of-network: $0 copay

Vision

Routine eye exam In-network: $0 copay
Out-of-network: $0 copay

Contact lenses In-network: $0 copay
Out-of-network: $0 copay

Eyeglasses (frames & lenses) In-network: $0 copay
Out-of-network: $0 copay

Eyeglass frames (only) In-network: $0 copay
Out-of-network: $0 copay

Eyeglass lenses (only) In-network: $0 copay
Out-of-network: $0 copay

Upgrades In-network: $0 copay
Out-of-network: $0 copay

Plan documents & tools

Plan details (carrier site)Provider directory Drug list (formulary)

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