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DEVOTED CHOICE GIVEBACK 011 GA (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 011 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 011 GA (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 011 GA (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Augusta and Savannah. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 011 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 011 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 011 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 $164.80. 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 011 GA (PPO) medicare plan features an annual drug deductible of $605. For Tier 1 preferred generic medications, you will enjoy no copay for one, two, or three-month supplies at standard pharmacies and standard mail order. Tier 2 generic drugs are also highly affordable, with standard copays starting at $3.00 for a one-month supply and capped at $7.50 for a three-month mail-order supply. Higher-tier medications are covered via coinsurance rather than flat copayments. Tier 3 preferred brand drugs require a 21% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance for standard pharmacy and mail-order fills. These coinsurance rates apply to all available supply lengths, with specialty tier drugs limited to a one-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 011 GA (PPO) Medicare plan offers robust medical coverage with no copay and no coinsurance for primary care doctor visits and routine preventive services. For inpatient hospital stays, members pay a $475 daily copay for the first four days and no copay for days 5 through 90. Emergency room visits feature a $115 copay, which is waived upon admission, while urgent care visits range from no copay to a $40 copay. Additional benefits include routine dental care with no copay for most preventive and comprehensive services up to a $250 annual limit, as well as routine eye exams and a $200 yearly eyewear allowance. Routine hearing exams are covered with a $45 copay, and prescription hearing aids require copays between $599 and $899. Home health services, diagnostic lab tests, and skilled nursing facility stays for the first 20 days are also covered with no copay.
Inpatient Hospital See details
Inpatient hospital services are covered by DEVOTED CHOICE GIVEBACK 011 GA (PPO) with no coinsurance, requiring a $475 copay for days 1 through 4 and no copay for days 5 through 90 per stay. The benefit is partially covered because unlimited additional days are included for acute care, while additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED CHOICE GIVEBACK 011 GA (PPO) covers outpatient services with no coinsurance, including outpatient hospital services with a $0 to $575 copay and observation services with a $475 copay per stay. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions require a $45 copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization benefits are covered by the DEVOTED CHOICE GIVEBACK 011 GA (PPO) plan with a $70.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 011 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, both of which require prior authorization. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
DEVOTED CHOICE GIVEBACK 011 GA (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services with no copay to a $40 copay and no coinsurance. Worldwide emergency services are covered up to a $25,000 maximum, featuring a $115 copay and no coinsurance for emergency and urgent care, and a $315 copay with 20% coinsurance for emergency transportation.
Primary Care See details
Primary care services under DEVOTED CHOICE GIVEBACK 011 GA (PPO) feature no copay and no coinsurance for primary care physician visits, while chiropractic and podiatry services are not covered. Other covered benefits, such as specialist visits, therapy, and mental health services, require copays ranging from $0 to $50 and no coinsurance.
Preventive Services See details
Preventive services are covered by DEVOTED CHOICE GIVEBACK 011 GA (PPO) with no copay and no coinsurance, including annual physicals, kidney disease education, and diabetes self-management. Additional preventive benefits are partially covered, providing fitness programs, weight management, and home safety devices, but excluding services like therapeutic massage, in-home support, personal emergency response systems, and medical nutrition therapy.
Hearing Services See details
Hearing services are partially covered by the DEVOTED CHOICE GIVEBACK 011 GA (PPO) plan, which features routine hearing exams for a $45 copay and no coinsurance. Prescription hearing aids are covered with a copay ranging from $599 to $899 and no coinsurance, though OTC hearing aids and inner ear, outer ear, or over the ear prescription aids are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE GIVEBACK 011 GA (PPO) because other eye exam services are not covered. Covered benefits include one routine eye exam per year with a $0 to $45 copay and no coinsurance, alongside a $200 annual maximum for eyewear with no copay and no coinsurance.
Dental Services See details
Dental services are covered by DEVOTED CHOICE GIVEBACK 011 GA (PPO) with no copay and no coinsurance for most preventive and comprehensive care, up to a $250 annual maximum for both in- and out-of-network services. Medicare-covered dental services require a $45 copay and no coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 011 GA (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs have no copay and 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by DEVOTED CHOICE GIVEBACK 011 GA (PPO) with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 011 GA (PPO) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment carries a 20% coinsurance, while prosthetics, medical supplies, and diabetic supplies range from no coinsurance to 20% coinsurance, with diabetic therapeutic shoes and inserts not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the DEVOTED CHOICE GIVEBACK 011 GA (PPO) plan, with prior authorization required. Lab services have no copay and no coinsurance, diagnostic procedures and tests require no coinsurance and a copay of $0 to $95, and radiological services range from a $0 minimum copay for diagnostic scans to a 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered under the DEVOTED CHOICE GIVEBACK 011 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 GIVEBACK 011 GA (PPO) with no coinsurance, though in practice some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require copayments ranging from $20 to $30.
Skilled Nursing Facility (SNF) See details
DEVOTED CHOICE GIVEBACK 011 GA (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the standard 100-day benefit period are not covered.
Other Services See details
Other Services are partially covered by DEVOTED CHOICE GIVEBACK 011 GA (PPO), 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.
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