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DEVOTED CHOICE 004 GA (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE 004 GA (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED CHOICE 004 GA (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE 004 GA (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Greater Georgia. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE 004 GA (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 004 GA (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 004 GA (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.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 $370.00 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 $13900.00 (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 $13900.00 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 004 GA (PPO) Medicare plan features an annual prescription drug deductible of $370. Members enjoy no copay for both Tier 1 (Preferred Generic) and Tier 2 (Generic) medications when using standard pharmacies or standard mail order services for 1-month, 2-month, or 3-month supplies. This ensures that essential generic drugs remain highly affordable throughout the year. For brand-name and specialty prescriptions, costs are calculated as a percentage of the drug price. Tier 3 (Preferred Brand) drugs require a 19% coinsurance, and Tier 4 (Non-Preferred) drugs carry a 25% coinsurance for standard retail and mail-order fills. Tier 5 (Specialty Tier) medications have a 28% coinsurance for a 1-month supply.
Additional Benefits
The DEVOTED CHOICE 004 GA (PPO) plan offers comprehensive medical coverage featuring no copays for primary care visits, preventive services, and home health care. Specialist visits require a predictable $30 copay, while inpatient hospital stays incur a $350 daily copay for the first seven days followed by no copay for additional days. Outpatient hospital services feature copays ranging from no copay up to $450, with no coinsurance required for standard hospital services. This plan also includes valuable supplemental benefits, such as dental coverage up to a $3,500 annual limit with no copay for preventive dental care. Members can also take advantage of a $350 annual eyewear allowance, routine hearing exams, and a $100 quarterly over-the-counter allowance. These additional benefits help reduce out-of-pocket costs for essential everyday health and wellness needs.
Inpatient Hospital See details
DEVOTED CHOICE 004 GA (PPO) covers inpatient hospital services with no coinsurance, requiring a $350 daily copay for days 1 through 7 of acute stays (no copay for days 8 through 90) and days 1 through 5 of psychiatric stays (no copay for days 6 through 90). Prior authorization is required, and non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
DEVOTED CHOICE 004 GA (PPO) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and blood services. Patients will pay a copay of $0 to $450 for outpatient hospital services, $350 per stay for observation services, and $30 per session for individual or group outpatient substance abuse treatment.
Partial Hospitalization See details
Partial hospitalization is covered by DEVOTED CHOICE 004 GA (PPO) with a $70.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
DEVOTED CHOICE 004 GA (PPO) covers ground ambulance services with a copay of $0 to $315 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required. For transportation, some services are covered, but transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
Emergency services are covered by DEVOTED CHOICE 004 GA (PPO) with a $115 copay and no coinsurance, with the copay waived if admitted to the hospital within 24 hours. Urgently needed care ranges from no copay to a $40 copay with no coinsurance, and worldwide emergency services are covered up to $25,000 with a $115 copay and no coinsurance, or a $315 copay and 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE 004 GA (PPO) offers primary care physician services with no copay and no coinsurance, while specialist visits, psychiatric, and mental health services require a $30 copay and no coinsurance. Physical, occupational, and speech therapy services feature copays ranging from $30 to $50 with no coinsurance, podiatry is not covered, and some chiropractic services are covered but routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by DEVOTED CHOICE 004 GA (PPO) with no copay and no coinsurance for covered benefits like physical exams and fitness programs. Sub-services that are not covered under this plan include in-home safety assessments, personal emergency response systems, medical nutrition therapy, medication reconciliation, readmission prevention, wigs, therapeutic massage, adult day health, palliative care, in-home support, caregiver support, additional smoking cessation, disease management, telemonitoring, remote access, and counseling.
Hearing Services See details
Hearing services are partially covered by DEVOTED CHOICE 004 GA (PPO), which offers annual routine hearing exams for a $30 copay and no coinsurance, subject to prior authorization. Covered prescription hearing aids require a copay between $399 and $699 with no coinsurance (limit of two per year), while OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
DEVOTED CHOICE 004 GA (PPO) vision services are partially covered, as other eye exam services are not covered. Routine eye exams are covered with a $0 to $30 copay and no coinsurance (limited to one per year), while eyewear is covered with no copay or coinsurance up to a $350 annual maximum.
Dental Services See details
DEVOTED CHOICE 004 GA (PPO) dental services are partially covered up to a $3,500 annual limit, offering preventive care, periodontics, and oral surgery with no copay and no coinsurance. Restorative, endodontic, and prosthodontic services have no copay and 0% to 50% coinsurance, and Medicare-covered dental has a $30 copay and no coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED CHOICE 004 GA (PPO) with no copay, while associated Medicare Part B chemotherapy and other drugs carry no copay and a 0% to 20% coinsurance. Covered Medicare Part B insulin drugs require a $35 copay and 0% to 20% coinsurance, with prior authorization and step therapy rules applying.
Dialysis Services See details
Dialysis Services are covered by DEVOTED CHOICE 004 GA (PPO) with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED CHOICE 004 GA (PPO) partially covers medical equipment with no copays, requiring a 20% coinsurance for durable medical equipment (DME) and no coinsurance to 20% coinsurance for prosthetics, medical supplies, and diabetic supplies. Prior authorization is required, and diabetic therapeutic shoes and inserts are not covered under this plan.
Diagnostic and Radiological Services See details
DEVOTED CHOICE 004 GA (PPO) covers diagnostic and radiological services with prior authorization required, offering lab services, outpatient X-rays, and diagnostic radiology with no copays. Diagnostic procedures and tests have a copay ranging from $0 to $95 with no coinsurance, while therapeutic radiological services require a 20% minimum coinsurance.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE 004 GA (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by DEVOTED CHOICE 004 GA (PPO) with no coinsurance and require prior authorization. While some services are covered, standard cardiac rehabilitation ($30 copay), intensive cardiac rehabilitation ($30 copay), pulmonary rehabilitation ($25 copay), and supervised exercise therapy for peripheral artery disease ($20 copay) are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE 004 GA (PPO) covers Skilled Nursing Facility (SNF) care with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, while days 21 through 100 require a $218 daily copay, with additional days beyond the standard Medicare benefit not covered.
Other Services See details
DEVOTED CHOICE 004 GA (PPO) partially covers other services, offering over-the-counter (OTC) items and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and other select services are not covered, and the OTC benefit is limited to $100 every three months.
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