Devoted CHOICE GIVEBACK Georgia (PPO)

Devoted CHOICE GIVEBACK Georgia (PPO) H5453-011 Plan Details
Plan too new to be measured

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 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 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 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.

Devoted CHOICE GIVEBACK Georgia (PPO) H5453-011 Plan Details
Plan too new to be measured

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 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

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:
  • INN: $425 per day from day 1
  • $0 per day from day 5
  • OON: $425 per day from day 1
  • $0 per day from day 5
  • PA may be required
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
  • Maximum 1 Routine Eye Exam every year

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
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0

Hearing Aids:
Copayment for Hearing Aids $599 to $899
  • Maximum 2 Hearing Aids every year
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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    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
    • Standard retail $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $10.00
    • Standard mail order $10.00
    Annual Drug Deductible $590 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $20.00
    • Standard mail order $20.00
    Annual Drug Deductible $590 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $30.00
    • Standard mail order $25.00