DEVOTED GIVEBACK 005 TN (HMO)
$0.00 /month
Monthly Premium
Among the lowest-premium plans in 2026
$605.00
Annual Deductible
995
Drugs Covered
1
States Served
Top Covered Drugs
Most popular medications covered by this plan, ordered by national search frequency. Click any drug to see exact copay, restrictions, and alternatives.
| # | Drug Name | Type | Tier | 30-Day Copay | |
|---|---|---|---|---|---|
| 1 | Fetzima LEVOMILNACIPRAN HYDROCHLORIDE | Brand | Tier 4 | $0.00 | Details |
| 2 | Warfarin Sodium | Brand | Tier 1 | $0.00 | Details |
| 3 | Prochlorperazine | Brand | Tier 4 | $0.00 | Details |
| 4 | ELIQUIS apixaban | Brand | Tier 3 | $0.00 | Details |
| 5 | Nefazodone Hydrochloride | Brand | Tier 4 | $0.00 | Details |
| 6 | GARDASIL 9 Human Papillomavirus 9-valent Vaccine, Recombinant | Brand | Tier 1 | $0.00 | Details |
| 7 | VAQTA hepatitis A vaccine, inactivated | Brand | Tier 1 | $0.00 | Details |
| 8 | Diazepam | Brand | Tier 3 | $0.00 | Details |
| 9 | Nitroglycerin nitroglycerin | Brand | Tier 3 | $0.00 | Details |
| 10 | Amoxicillin and Clavulanate Potassium | Brand | Tier 3 | $0.00 | Details |
| 11 | Estradiol | Brand | Tier 2 | $0.00 | Details |
| 12 | Mefloquine Hydrochloride | Brand | Tier 3 | $0.00 | Details |
| 13 | Imatinib Mesylate | Brand | Tier 3 | $0.00 | Details |
| 14 | Methylphenidate Hydrochloride | Brand | Tier 3 | $0.00 | Details |
| 15 | Talzenna talazoparib | Brand | Tier 5 | $0.00 | Details |
| 16 | Fiasp insulin aspart injection | Brand | Tier 3 | $0.00 | Details |
| 17 | HYDROCODONE BITARTRATE AND ACETAMINOPHEN | Brand | Tier 3 | $0.00 | Details |
| 18 | bexarotene | Brand | Tier 5 | $0.00 | Details |
| 19 | Budesonide | Brand | Tier 4 | $0.00 | Details |
| 20 | Clozapine | Brand | Tier 4 | $0.00 | Details |
Showing 20 of 995 covered drugs.
States Served (1)
This plan is available to Medicare beneficiaries in the following states.
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