Devoted CHOICE Georgia (PPO)
Devoted CHOICE Georgia (PPO) H5453-010 Plan Details
Devoted CHOICE Georgia (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H5453-010
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
Devoted CHOICE Georgia (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H5453-010
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $590 |
| Out of Pocket Max |
In-Network: $6350 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $15 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $35 Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $15 to $35 |
| Inpatient Hospital Care | In Network Inpatient Hospital Coverage:
|
| Urgent Care | Copayment for Urgent Care $0 to $45 $0 copay for urgently needed services received by a PCP.$45 copay for urgently needed services received from an urgent care center. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125 |
| Emergency Room Visit | Copayment for Emergency Care $125 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Copayment for Worldwide Emergency Transportation $290 |
| Ambulance Transportation | In Network Ground Ambulance INN: $290 OON: $290 PA may be required Air or Water Ambulance INN: 20% OON: 20% PA may be required Facility to Facility Transfer Member will not be responsible for additional ground ambulance copays for facility to facility transfers. |
Health Care Services and Medical Supplies
Devoted CHOICE Georgia (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In Network Chiropractic Services - Medicare Covered Copayment INN: $20 OON: $20 Chiropractic Services - Routine Visits Copayment Not covered |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In Network Copayment for Medicare-covered Diabetic Supplies INN: $0 OON: 40% PA may be required Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts INN: $0 OON: 40% PA may be required |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment Plan covers crutches with 20% coinsurance.The following DME has 20% coinsurance:Medicare-covered ventilator, Bone growth stimulator, Portable oxygen concentrator, Bariatric equipment, Specialty beds, Custom or specialty wheelchairs and scooters, Seat lifts, Specialty brand items, High Frequency Chest Compression Vests, Pain Infusion Pump, Continuous Glucose Monitor (other than Plan's preferred CGM), and Home Infusion Therapy (HIT) drugs.$0 copay for the Plan's preferred Continuous Glucose Monitor.20% coinsurance for all other DME. Prior authorization required Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 0% to 50% Plan covers crutches with 20% coinsurance.The following DME has 20% coinsurance:Medicare-covered ventilator, Bone growth stimulator, Portable oxygen concentrator, Bariatric equipment, Specialty beds, Custom or specialty wheelchairs and scooters, Seat lifts, Specialty brand items, High Frequency Chest Compression Vests, Pain Infusion Pump, Continuous Glucose Monitor (other than Plan's preferred CGM), and Home Infusion Therapy (HIT) drugs.$0 copay for the Plan's preferred Continuous Glucose Monitor.20% coinsurance for all other DME. |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $95 Copayment for Medicare-covered Lab Services $0 to $20 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Copayment varies based on site of service:PCPs office: $0 copay for EKGs/EEGs/ECGs, $0 copay all other. Specialist office: $0 copay for EKGs/EEGs/ECGs, $40 copay all other. Freestanding facility: $40 copay for EKGs/EEGs/ECGs, $40 copay all other. Outpatient hospital: $95 copay for EKGs/EEGs/ECGs, $95 copay all other. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $300 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $75 Prior authorization required Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0 to $95 Copayment for Medicare Covered Lab Services $0 to $20 Coinsurance for Medicare Covered Lab Services 20% Copayment for Medicare Covered Diagnostic Radiological Services $0 to $300 Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Copayment for Medicare Covered Outpatient X-Ray Services $0 to $75 Copayment varies based on site of service:PCPs office: $0 copay for EKGs/EEGs/ECGs, $0 copay all other. Specialist office: $0 copay for EKGs/EEGs/ECGs, $40 copay all other. Freestanding facility: $40 copay for EKGs/EEGs/ECGs, $40 copay all other. Outpatient hospital: $95 copay for EKGs/EEGs/ECGs, $95 copay all other. |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 40% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $350 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Psychiatric Hospital Services: $350 per day for days 1 to 6 $0 per day for days 7 to 90 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $35 Copayment for Medicare-covered Group Sessions $35 Out-of-Network: Medicare Covered Mental Health Services: Copayment for Medicare Covered Individual Sessions $35 Copayment for Medicare Covered Group Sessions $35 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $450 Prior Authorization Required for Outpatient Hospital Services $0 copay for diagnostic colonoscopies, $450 copay for all other outpatient hospital services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $350 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $350 Prior Authorization Required for Ambulatory Surgical Center Services $0 copay for diagnostic colonoscopies, $350 copay for all other ASC services. Prior authorization required Out-of-Network: Medicare Covered Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $450 Copayment for Medicare Covered Ambulatory Surgical Center Services $0 to $450 $0 copay for diagnostic colonoscopies, $450 copay for all other outpatient hospital services. |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $35 Copayment for Medicare-covered Group Sessions $35 Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $35 Copayment for Medicare Covered Group Sessions $35 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $35 Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $35 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In Network This plan has a: Dental/Eyewear Allowance. Copayment for Medicare Covered Dental Services: INN: $35 OON: $35 PA may be required Preventive & Comprehensive Dental Services: You have a $1000 yearly allowance toward Preventive Dental, Comprehensive Dental, and/or Eyewear combined. You can see any licensed dentist or visit any eyewear retailer. You'll pay the costs yourself at first. Then, you can submit a request for reimbursement to Devoted. Cosmetic procedures, dental implants, and/or elective procedures are not covered. Please see Summary of Benefits and Evidence of Coverage for more benefit information. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In Network In-Network: Eye Exams: Copayment for Medicare Covered Benefits $35 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $1,000 every year. Allowance may be combined with comprehensive dental benefits. Please see Summary of Benefits and Evidence of Coverage for more benefit information. Out of Network Out-of-Network: Medicare Covered Eye Exams Services: Copayment for Medicare Covered Eye Exams $35 Copayment for Medicare Covered Eyewear $0 |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $35 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $399 to $699
Out-of-Network: Medicare Covered Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $35 |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
Prescription Drug Costs and Coverage
The Devoted CHOICE Georgia (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $590 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
