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Devoted CHOICE Georgia (PPO) - H5453-001-000

Plan too new to be measured* for plan year 2025

$0.00

Monthly Premium

Devoted CHOICE Georgia (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Devoted Health

Plan ID: H5453-001-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

Georgia Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Georgia Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$590.00
Out-of-pocket maximum$6,300.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visit
Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $15
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit Services:
Copayment for Medicare Covered Physician Specialist Office Visit $15 to $30
Inpatient hospital careIn Network
Inpatient Hospital Coverage:
  • INN: $350 per day from day 1
  • $0 per day from day 8
  • OON: $350 per day from day 1
  • $0 per day from day 8
  • PA may be required
Urgent care
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
Emergency Care:
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 transportationIn 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 a range of additional benefits. Learn more about Devoted CHOICE Georgia (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn Network
Chiropractic Services - Medicare Covered Copayment
INN: $20
OON: $20

Chiropractic Services - Routine Visits Copayment
Not covered
Diabetes supplies, training, nutrition therapy and monitoringIn 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 equipment (DME)
Out-of-Network:

Medicare Covered Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 0% to 40%
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-raysIn-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
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental health inpatient care
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 careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $30
Copayment for Medicare-covered Group Sessions $30
Outpatient services/surgery
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
Out-of-Network:

Medicare Covered Outpatient Substance Abuse Services:
Copayment for Medicare Covered Individual Sessions $30
Copayment for Medicare Covered Group Sessions $30
Podiatry services
Out-of-Network:

Medicare Covered Podiatry Services:
Copayment for Medicare Covered Podiatry Services $30
Skilled Nursing Facility (SNF) careIn-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

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental careIn Network
This plan has a: Dental/Eyewear Allowance.

Copayment for Medicare Covered Dental Services:
INN: $30
OON: $30
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, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision careIn Network
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $30
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year

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 $30
Copayment for Medicare Covered Eyewear $0

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $30
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 $399 to $699
  • Maximum 2 Hearing Aids every year

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programs
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) offers prescription drug coverage, with an annual drug deductible of $590.00 (excludes Tiers 1 and 2)

Coverage & Cost
Coverage
Cost
Annual drug deductible$590.00 (excludes Tiers 1 and 2)
Tier 1
  • Standard retail $0.00
  • Standard mail order $0.00
Tier 2
  • Standard retail $0.00
  • Standard mail order $0.00
Annual drug deductible$590.00 (excludes Tiers 1 and 2)
Tier 1
  • Standard retail $0.00
  • Standard mail order $0.00
Tier 2
  • Standard retail $0.00
  • Standard mail order $0.00
Annual drug deductible$590.00 (excludes Tiers 1 and 2)
Tier 1
  • Standard retail $0.00
  • Standard mail order $0.00
Tier 2
  • Standard retail $0.00
  • Standard mail order $0.00

When reviewing Georgia Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Georgia that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Georgia Counties Served

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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