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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 Georgia. 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 $147.70. 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 depending on the drug tier and pharmacy. For example, for a standard pharmacy, you'll pay a $10 copay for preferred generic drugs, 25% coinsurance for standard generic and preferred brand drugs, and 25% coinsurance for non-preferred drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Devoted CHOICE GIVEBACK Georgia (PPO) plan offers a range of benefits with varying costs. It covers inpatient hospital stays with a copay, outpatient services with copays, and emergency services with copays. The plan also includes coverage for primary care, preventive services, hearing, vision, and dental services, with specific copays and annual limits. This plan provides coverage for home health services, skilled nursing facility stays, and home infusion services, with associated copays or coinsurance. However, it excludes certain services like cardiac rehabilitation, acupuncture, and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For days 1-4, the copay is $475, and for days 5-90, there is no copay; there is no coinsurance.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with copays ranging from $0 to $575, observation services with a $475 copay, ambulatory surgical center services with no copay, individual and group outpatient substance abuse sessions with a copay of $45, and outpatient blood services. Prior authorization is required for some services.
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
For the Devoted CHOICE GIVEBACK Georgia (PPO) plan, Ambulance and Transportation Services are covered. Ground ambulance services have a copay of $0-$300, while air ambulance services have a 20% coinsurance. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $110 copay, and no coinsurance. Urgently Needed Services have a copay between $0 and $45, and no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, and no coinsurance. Worldwide Emergency Transportation has a $300 copay and 20% coinsurance.
Primary Care See details
The Devoted CHOICE GIVEBACK Georgia (PPO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy with a $35 copay, physician specialist services with a $45 copay, mental health specialty services with a $45 copay for individual and group sessions, other health care professional services with a copay from $0-$45, psychiatric services with a $45 copay for individual and group sessions, physical therapy and speech-language pathology services with a copay from $45-$50, additional telehealth benefits with a copay from $0-$45, and opioid treatment program services with 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 and modifications, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit. However, in-home safety assessment, personal emergency response system, medical nutrition therapy, 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, as well as fitting/evaluation for hearing aids with no copay. Prescription Hearing Aids (all types) are covered with a copay between $599 and $899 for 2 visits every year, but Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered, and OTC Hearing Aids are not covered.
Vision Services See details
Vision Services include eye exams with a $20 copay, along with coverage for eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames, with a combined maximum benefit of $250 every year. Routine eye exams are covered once per year.
Dental Services See details
The Devoted CHOICE GIVEBACK Georgia (PPO) plan covers Medicare Dental Services with a $45 copay. Other Dental Services, including oral exams, dental x-rays, and more are covered, with a maximum benefit of $250 per year. However, 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.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE GIVEBACK Georgia (PPO) plan with a coinsurance of 20%.
Medical Equipment See details
Medical equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetic Devices with a 0-20% coinsurance; however, DME for use outside the home is not covered. Medical Supplies have a 20% coinsurance, and 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. Diagnostic Procedures/Tests have a copay between $0 and $95, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $300, and 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, but require authorization. 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. Although the plan covers some cardiac and pulmonary rehabilitation services, those specific services are not covered.
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, a $214 copay for days 21-60, and no copay for days 61-100.
Other Services See details
The Devoted CHOICE GIVEBACK Georgia (PPO) plan does not cover acupuncture, over-the-counter items, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services. Other services are covered, and there is no copay for $0 Preventive Services.
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