Devoted CHOICE GIVEBACK Georgia (PPO)
Devoted CHOICE GIVEBACK Georgia (PPO) H5453-011 Plan Details
Devoted CHOICE GIVEBACK Georgia (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H5453-011
HelpAdvisor Editorial Team analysis of data from the 2025 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.
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Monthly Premium
Devoted CHOICE GIVEBACK Georgia (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H5453-011
HelpAdvisor Editorial Team analysis of data from the 2025 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: $9350 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 $45 Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $15 to $45 |
| 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 $110 |
| Emergency Room Visit | Copayment for Emergency Care $110 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 $110 Copayment for Worldwide Emergency Transportation $300 |
| Ambulance Transportation | In Network Ground Ambulance INN: $300 OON: $300 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 GIVEBACK 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: $15 OON: $15 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: 20% PA may be required Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts INN: $0 OON: 20% PA may be required |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 20% |
| 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 $50 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 $50 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: $425 per day for days 1 to 4 $0 per day for days 5 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Psychiatric Hospital Services: $425 per day for days 1 to 4 $0 per day for days 5 to 90 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $45 Copayment for Medicare-covered Group Sessions $45 Out-of-Network: Medicare Covered Mental Health Services: Copayment for Medicare Covered Individual Sessions $45 Copayment for Medicare Covered Group Sessions $45 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $575 Prior Authorization Required for Outpatient Hospital Services $0 copay for diagnostic colonoscopies, $575 copay for all other outpatient hospital services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $475 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $475 Prior Authorization Required for Ambulatory Surgical Center Services $0 copay for diagnostic colonoscopies, $475 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 $575 Copayment for Medicare Covered Ambulatory Surgical Center Services $0 to $575 $0 copay for diagnostic colonoscopies, $575 copay for all other outpatient hospital services. |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $45 Copayment for Medicare-covered Group Sessions $45 Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $45 Copayment for Medicare Covered Group Sessions $45 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $45 Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $45 |
| 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: $45 OON: $45 PA may be required Preventive & Comprehensive Dental Services: You have a $250 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 $45 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $250 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 $45 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 $45 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $599 to $899
Out-of-Network: Medicare Covered Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $45 |
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 GIVEBACK 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 |
|
