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Devoted CHOICE GIVEBACK Georgia (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE GIVEBACK Georgia (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted CHOICE GIVEBACK Georgia (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE GIVEBACK Georgia (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Greater Atlanta. The overall rating for this plan is not yet available for 2025.
It's important to know that Devoted CHOICE GIVEBACK Georgia (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Devoted CHOICE GIVEBACK Georgia (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Devoted CHOICE GIVEBACK Georgia (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $167.70. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $10000.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $10000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Devoted CHOICE GIVEBACK Georgia (PPO) plan has a $590 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy. For example, you may pay a $10 copay for a preferred generic drug at a standard or mail-order pharmacy. For other tiers, you may pay 25% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for your Part D covered drugs.
Additional Benefits
The Devoted CHOICE GIVEBACK Georgia (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services have copays that vary by service. The plan also covers services like primary care, preventive services, hearing, vision, dental, and home health services with copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with prior authorization. For the first 5 days, the copay is $395 per day, and there is no copay for days 6-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services includes coverage for all outpatient hospital services, observation services, and outpatient substance abuse services. Outpatient hospital services have a copay between $0 and $495, observation services have a $395 copay, and ambulatory surgical center services have no copay. Individual and group sessions for outpatient substance abuse have a copay of $45. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE GIVEBACK Georgia (PPO) plan, with a $70 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
The Devoted CHOICE GIVEBACK Georgia (PPO) plan covers ambulance services, with a copay of $0-$300 for ground ambulance services and 20% coinsurance for air ambulance services. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered under the Devoted CHOICE GIVEBACK Georgia (PPO) plan. Emergency Services have a $110 copay, Urgently Needed Services have a copay between $0 and $45, and Worldwide Emergency Services have a copay of $110 for Worldwide Emergency Coverage and Worldwide Urgent Coverage, and a $300 copay and 20% coinsurance for Worldwide Emergency Transportation.
Primary Care See details
Primary Care Physician services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Chiropractic Services has a $15 copay, Physician Specialist Services have a $45 copay, Individual and Group Sessions for Mental Health Specialty Services and Psychiatric Services have a $45 copay, Physical Therapy and Speech-Language Pathology Services have a $45-$50 copay, Opioid Treatment Program Services have a $45 copay, and Additional Telehealth Benefits range from no copay to a $45 copay. Routine chiropractic care and Podiatry Services are not covered.
Preventive Services See details
The Devoted CHOICE GIVEBACK Georgia (PPO) plan covers preventive services, including annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit. Some services like in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy (MNT), post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, and counseling services are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $45 copay, and routine hearing exams with a limit of one visit per year. Prescription hearing aids (all types) are covered with a copay between $599 and $899, but prescription hearing aids for the inner, outer, and over the ear are not covered, and OTC hearing aids are also not covered.
Vision Services See details
Vision services include coverage for eye exams with a $45 copay, and also cover eyewear with a combined maximum benefit of $250 per year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The Devoted CHOICE GIVEBACK Georgia (PPO) plan covers dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. Medicare Dental Services have a $45 copay. Other dental services have a maximum benefit of $250 per year. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 20% coinsurance, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE GIVEBACK Georgia (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the Devoted CHOICE GIVEBACK Georgia (PPO) plan. Durable Medical Equipment (DME) has a 16% coinsurance and requires prior authorization, but Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies - Non-Medicare benefits are covered with no copay, and include coinsurance for Medicare-covered prosthetic devices and medical supplies. Medical supplies have a 20% coinsurance, while Prosthetic Devices have a 0-20% coinsurance. Diabetic Equipment is covered, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have a copay between $0 and $95, and Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $300, while Therapeutic Radiological Services have a coinsurance of at least 20%. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK Georgia (PPO) plan with no copay and no coinsurance, although authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted CHOICE GIVEBACK Georgia (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE GIVEBACK Georgia (PPO) plan, but require prior authorization. There is no copay for days 1-20 and days 61-100, and a $214 copay for days 21-60.
Other Services See details
Other Services are not covered by the Devoted CHOICE GIVEBACK Georgia (PPO) plan, including acupuncture, over-the-counter items, and meal benefits. Additional services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and Case Management (Long Term Care) are also not covered.
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