Medicare Advantage Plan HMO H3407_003

El Paso Health Giveback (HMO)

A value plan that has health, dental, vision, and hearing care at a low premium.
This plan has prescription drug coverage.
$0.00
Monthly Premium
$8,450
Maximum out-of-pocket
$120
Part B Premium Reduction
Enroll Now
Medicare Annual Enrollment begins on October 15.
Starting on this date, you can enroll in one of our Medicare Advantage plans that include prescription drug coverage.
keyboard_arrow_down
General Costs
Premium & Deductibles
In-Network
Monthly Plan Premium
$0
Medical Deductible
$0
Maximum Out-of-Pocket
$8,450
The maximum out of pocket is the amount that you will pay in deductibles, co-payments, and coinsurance on covered services. It does not include the amount you pay for monthly premiums.
keyboard_arrow_down
Doctor Costs & Coverage
Covered Doctor Copays
In-Network
Primary Care Copay
$0 copay
Specialist copay
$35 copay
keyboard_arrow_down
Prescription Drug Costs & Coverage
The cost of your medicine depends on where you buy it, how much you get and whether it is a generic, brand or specialty drug. For more details, see the pharmacy chart in the Summary of Benefits.
Prescription Drug Costs
Tier 1 - Preferred Generic
$0 copay
Tier 2 - Generic
$0 copay
Tier 3 - Preferred Brand
20% coinsurance
Tier 4 - Non-Preferred Drug
27% coinsurance
Tier 5 - Specialty Drugs
25% coinsurance
Tier 6 - Supplemental Drugs
$0 copay
keyboard_arrow_down
Hospital & X-Ray Costs
Hospital & Urgent Care
In-Network
Inpatient Hospital Care
$400 copay per day for day 1 to 5
$0 copay per day for day 6 to 90
Outpatient Hospital Facility Services
$500 copay
Emergency Room
$115 copay
If you are admitted to the same hospital within 24 hours, you do not have to pay your share of the cost for the emergency care.
Urgent Care
$40 copay
Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical attention.
Radiology & X-Rays
In-Network
Cost share may vary depending on the service and where service is provided.
Radiology Services In-Office
$75 copay
Radiology Services in a Facility
$200 copay
Outpatient X-Ray In-Office
$0 copay
Outpatient X-Ray in a Facility
$70 copay

Primary Benefits

keyboard_arrow_down
Mental Health Services
Mental Health Services
In-Network
Inpatient Care at a Psychiatric Facility
$400 copay per day for day 1 to 5 and
$0 copay per day for day 6 to 90
Your plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital.
Outpatient Mental Group Therapy
$35 copay
Outpatient Mental Individual Therapy Visit
$35 copay
keyboard_arrow_down
Dental Coverage
Dental Benefits
In-Network
Medicare-covered dental services
$35 copay
Routine Dental
In-Network
Bitewing x-rays up to 1 set(s) per year  
$0 copay
Comprehensive oral evaluation or periodontal exam up to 1 every 3 years
$0 copay
Periodic oral exam up to 2 per year
$0 copay
Prophylaxis (cleaning) up to 2 per year
$0 copay
Amalgam and/or composite filling up to unlimited per year
$0 copay
Necessary anesthesia with covered service up to unlimited per year
$0 copay
Simple or surgical extraction up to unlimited per year 
$0 copay
Maximum benefit
$750 maximum benefit coverage amount per year
keyboard_arrow_down
Vision Coverage
Vision Benefits
In-Network
Additional vision benefits may be available. For more information see the Summary of Benefits.
Medicare-covered Vision Services
$35 copay
Routine Vision
In-Network
Routine Exam up to 1 per year
$0 copay
Max benefit: contact lenses or eyeglasses-lenses and frames, fitting for eyeglasses-lenses and frames
$200 maximum benefit coverage amount per year
keyboard_arrow_down
Hearing Coverage
Hearing Benefits
In-Network
Additional hearing benefits may be available with a separate monthly premium. For more information see the Summary of Benefits.
Medicare-covered Hearing Services
$30 copay
Routine Hearing
In-Network
Entry level hearing aid once every 2 years
$525 copay
Basic level hearing aid once every 2 years
$700 copay
Premium level hearing aid once every 2 years
$1,000 copay
keyboard_arrow_down
Preventative Coverage
Preventative Benefits
In-Network
In-network: $0 for the following preventive services when you see an in-network provider:
‍
Bone mass measurement
Cervical and vaginal cancer screening
Medicare diabetes prevention program (MDPP)
Annual wellness visit
Colorectal cancer screening
Prostate cancer screening
Breast cancer screening (mammogram)
Diabetes screenings
Routine physical exam
Cardiovascular screenings
Immunizations
Lung cancer screening

Supplemental Benefits

keyboard_arrow_down
Get Fit Program
El Paso Health members can enjoy a cost-free Black Card membership at any Planet Fitness location, just show your member ID at the front desk. This benefit supports your fitness and well-being with access to top gym amenities at no extra cost.
keyboard_arrow_down
Home-Delivered Meals
Get up to fourteen (14) healthy meals delivered to your home after being discharged from a hospital or nursing facility.

How to get a meal delivered‍
Contact Member Services if you have been discharged from a hospital or nursing facility. Call us toll free 1-833-742-2121.
keyboard_arrow_down
24-Hour Nurse Line
Access to a 24-hour, seven days a week bilingual (English/Spanish) medical advice line staffed by nurses and pharmacists.

How to Call the 24-Hour Nurse Line‍
On the back of your El Paso Health Member card, you will find the 24-hour Nurse line.

Plan Documents

keyboard_arrow_down
2026 Plan Documents (Updated 10/01/2025 unless noted otherwise)
Summary of Benefits (CMS Accepted 08/30/2025)
View deductibles, copays, and more.
English Spanish
Provider Directory
Search the Provider Directory on El Paso Health's non-Medicare website or view and download the pdf below.
List of Providers
Pharmacy Directory
View our network of Pharmacies
English Spanish
Enrollment Form (CMS Accepted 06/09/2025)
Complete enrollment by filling out this form.
English Spanish
Printable Prescription Drug List
View our Comprehensive Formulary
English Spanish
Evidence of Coverage
See what's covered, and what you pay as a member of this plan.
Enroll Now

Licensed sales agents are here to answer your questions.

Find a plan that best suits your needs in just one phone call.
1-833-742-2121
TTY 711, 24/7
Back to Top
1145 Westmoreland Drive
El Paso, TX 79925-5615

El Paso Health Medicare Advantage Dual (HMO D-SNP)
1-833-742-3125

El Paso Health Giveback (HMO)
El Paso Health Total (HMO)
‍1-833-742-2121

See Hours of Operation here.
Facebook
Youtube
The information posted on this website may be available in other formats such as large print, Braille, and audio. You can request the materials in other formats by calling Member Services.
Last Updated: 10/01/2025
Member Support
Member Quality of Care Grievances and Appeals Clinical Practice Guidelines Medical Necessity Criteria
General Correspondence
P.O. Box 971100
El Paso, TX 79997-1100
You can also report fraud, waste and abuse directly to the Texas Office of Inspector General.
© El Paso Health Medicare Advantage
Fraud, Waste, and Abuse | Privacy Notice under the HIPAA | Non-Discrimination Notice | Privacy Policy | Medicare Compliance Program | Interoperability API Gateway
Notice
You are about to leave the El Paso Health Medicare website to visit:
Recorded Link Display