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DEVOTED CHOICE GIVEBACK 005 GA (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 005 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 GIVEBACK 005 GA (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 005 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 GIVEBACK 005 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 GIVEBACK 005 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 GIVEBACK 005 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. Additionally, this plan comes with a Part B Premium reduction of $164.10. 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 $605.00 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 005 GA (PPO) Medicare plan features an annual prescription drug deductible of $605. Beneficiaries enjoy no copay for Tier 1 preferred generic drugs through standard pharmacy and standard mail order services. For Tier 2 generic medications, copays range from $3 to $9 at standard pharmacies and $3 to $7.50 for standard mail orders depending on the supply. For higher-tier medications, cost-sharing is based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 21% coinsurance for standard pharmacy and mail order fills. Tier 4 non-preferred drugs and Tier 5 specialty drugs both require a 25% coinsurance, with specialty coverage limited to a one-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 005 GA (PPO) plan offers robust medical coverage, featuring no copays for primary care visits, preventive services, and home health care. For inpatient hospital stays, members pay no coinsurance and a $475 daily copay for the first four days, with no copay for days five through ninety. Specialist visits require a $45 copay, while emergency room services have a $115 copay, which is waived if you are admitted. This plan also includes essential specialty benefits, offering no copays for routine dental care up to a $250 annual limit and no copay for eyewear up to a $200 yearly allowance. Routine eye exams feature low copays up to $20, while hearing exams require a $45 copay with partial coverage for prescription hearing aids. Additionally, skilled nursing facility stays have no copay for the first 20 days, followed by a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 005 GA (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $475 daily copay for days 1 through 4 and no copay for days 5 through 90. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 005 GA (PPO) covers outpatient services with no coinsurance, featuring a copay of $0 to $475 for outpatient hospital services and $475 per stay for observation services. Ambulatory surgical center and outpatient blood services have no copay and no coinsurance, while outpatient substance abuse sessions require a $45 copay and no coinsurance.
Partial Hospitalization See details
DEVOTED CHOICE GIVEBACK 005 GA (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 005 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. Prior authorization is required for ambulance services, and transportation services to health-related locations are not covered.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 005 GA (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services have no copay to a $40 copay and no coinsurance, while worldwide emergency care is covered up to $25,000 with copays up to $315 and 20% coinsurance for transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 005 GA (PPO) offers primary care physician services with no copay and no coinsurance, and specialist visits with a $45 copay and no coinsurance. Additional services like physical, occupational, and mental health therapies require copays from $35 to $50 with no coinsurance, while podiatry is not covered, and for chiropractic care some services are covered but routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services are covered by DEVOTED CHOICE GIVEBACK 005 GA (PPO) with no copay and no coinsurance, including annual physical exams and kidney disease education. Additional preventive services are partially covered with no copay and no coinsurance, excluding sub-services such as in-home safety assessments, personal emergency response systems, medical nutrition therapy, therapeutic massage, and counseling.
Hearing Services See details
DEVOTED CHOICE GIVEBACK 005 GA (PPO) covers hearing exams with a $45 copay, no coinsurance, and no deductible, though prior authorization is required. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $599 to $899 for up to two devices per year, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
DEVOTED CHOICE GIVEBACK 005 GA (PPO) partially covers vision services, as other eye exam services are not covered. Routine eye exams are covered with a $0 to $20 copay and no coinsurance, while eyewear is covered with no copay, no coinsurance, and no deductible up to a $200 annual limit.
Dental Services See details
Dental services are partially covered by DEVOTED CHOICE GIVEBACK 005 GA (PPO), which features a $250 annual maximum benefit for combined in-network and out-of-network care. Preventive and most comprehensive dental services have no copay and no coinsurance, while Medicare-covered dental services require a $45 copay and no coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by DEVOTED CHOICE GIVEBACK 005 GA (PPO) with no copay and require prior authorization. Covered Part B chemotherapy, radiation, and other drugs have no copay and coinsurance ranging from no coinsurance to 20%, while Part B insulin requires a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
DEVOTED CHOICE GIVEBACK 005 GA (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Medical equipment is partially covered by DEVOTED CHOICE GIVEBACK 005 GA (PPO) with no copays, but prior authorization is required. Durable medical equipment incurs a 19% to 20% coinsurance, and covered prosthetics, medical supplies, and diabetic supplies range from no coinsurance to 20% coinsurance, though diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under DEVOTED CHOICE GIVEBACK 005 GA (PPO) with prior authorization required. Diagnostic services feature no coinsurance, offering lab services and outpatient X-rays at no copay, diagnostic tests with a $0 to $95 copay, and therapeutic radiological services with a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by DEVOTED CHOICE GIVEBACK 005 GA (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the DEVOTED CHOICE GIVEBACK 005 GA (PPO) plan with no copay and no coinsurance. While some services are covered, specific sub-services including standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) rehabilitation are not covered.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 005 GA (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and additional days beyond the standard Medicare limit are not covered.
Other Services See details
DEVOTED CHOICE GIVEBACK 005 GA (PPO) partially covers other services, offering additional preventive services not covered by Medicare with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered under this plan.
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