DEVOTED CHOICE GIVEBACK 005 GA (PPO)
Available to residents of Hancock County, GA for 2026. Contract H5453, plan 005, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Hancock County
- Plan website
- Browse the DEVOTED CHOICE GIVEBACK 005 GA (PPO) formulary
Renewed, service area reduced for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | $164.10 a month?You must continue to pay your Medicare Part B premium. |
| In-network out-of-pocket maximum | $9,250.00? |
| In- and out-of-network out-of-pocket maximum | $10,000.00 |
| Drug deductible | $605.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | PPO? |
| Contract / plan | H5453-005-0 |
| Offered by | Devoted Health |
| Parent organization | Devoted Health, Inc. |
| Formulary drugs | 3,377 |
| Formulary exception tier | 4? |
| Pharmacy search | www.devoted.com |
| Member services | (844)978-2770TTY 711 |
CMS star ratings
- Overall
- —
- Health plan (Part C)
- —
- Drug plan (Part D)
- —
Published per contract — every plan under contract H5453 shares this rating.
Plan health benefits
| Service | In-network | Out-of-network? |
|---|---|---|
| Doctor visits | ||
| Primary care doctor | $0 copay | $15 copay |
| Specialist | $45 copay(authorization required) | $45 copay |
| Other health care professional | $0–$45 copay(authorization required) | $0–$45 copay |
| Additional telehealth services | $0–$45 copay | — |
| Preventive care | ||
| Medicare-covered preventive services | $0 copay | $0 copay |
| Annual physical exam | $0 copay | $0 copay |
| Kidney disease education | $0 copay | $0 copay |
| Glaucoma screening | $0 copay | $0 copay |
| Diabetes self-management training | $0 copay | $0 copay |
| Diagnostic tests, labs and imaging | ||
| Diagnostic tests and procedures | $0–$95 copay(authorization required) | $0–$95 copay |
| Lab services | $0–$50 copay(authorization required) | $0–$50 copay; 20% coinsurance |
| Diagnostic radiology (e.g. MRI, CT) | $0–$300 copay(authorization required) | $0–$300 copay |
| Therapeutic radiology | 20% coinsurance(authorization required) | 40% coinsurance |
| Outpatient x-rays | $0–$75 copay(authorization required) | $0–$75 copay |
| Emergency and urgent care | ||
| Emergency room | $115 copay | — |
| Urgent care | $0–$40 copay | — |
| Worldwide emergency coverage | $115 copay · $25,000 plan limit | — |
| Worldwide urgent care | $115 copay · $25,000 plan limit | — |
| Worldwide emergency transportation | $315 copay; 20% coinsurance | — |
| Hospital care | ||
| Inpatient hospital stay | $475 per day for days 1–4; $0 per day for days 5–90(authorization required) | $475 per day for days 1–4; $0 per day for days 5–90 |
| Outpatient hospital services | $0–$475 copay(authorization required) | $0–$475 copay |
| Outpatient observation | $475 copay(authorization required) | $475 copay |
| Ambulatory surgical center | $0–$475 copay(authorization required) | $0–$475 copay |
| Outpatient blood services | $0 copay(authorization required) | $0 copay |
| Skilled nursing and home health | ||
| Skilled nursing facility | $0 per day for days 1–20; $218 per day for days 21–100(authorization required) | 37% coinsurance per stay |
| Home health care | $0 copay(authorization required) | 40% coinsurance |
| Kidney dialysis | 20% coinsurance(authorization required) | 20% coinsurance |
| Rehabilitation | ||
| Occupational therapy | $35 copay(authorization required) | $35 copay |
| Physical therapy and speech-language therapy | $45–$50 copay(authorization required) | $45–$50 copay |
| Cardiac rehabilitation | $30 copay(authorization required) | $30 copay |
| Pulmonary rehabilitation | $25 copay(authorization required) | $25 copay |
| Mental health and substance use | ||
| Inpatient psychiatric hospital stay | $475 per day for days 1–4; $0 per day for days 5–90(authorization required) | $475 per day for days 1–4; $0 per day for days 5–90 |
| Outpatient mental health, individual session | $45 copay(authorization required) | $45 copay |
| Outpatient mental health, group session | $45 copay(authorization required) | $45 copay |
| Psychiatrist, individual session | $45 copay(authorization required) | $45 copay |
| Psychiatrist, group session | $45 copay(authorization required) | $45 copay |
| Partial hospitalization | $70 copay(authorization required) | $70 copay |
| Intensive outpatient program | $70 copay(authorization required) | $70 copay |
| Outpatient substance use, individual session | $45 copay(authorization required) | $45 copay |
| Outpatient substance use, group session | $45 copay(authorization required) | $45 copay |
| Opioid treatment program | $45 copay(authorization required) | $45 copay |
| Ambulance and transportation | ||
| Ground ambulance | $0–$315 copay(authorization required) | $0–$315 copay |
| Air ambulance | 20% coinsurance(authorization required) | 20% coinsurance |
| Transportation to plan-approved locations | Not covered | — |
| Medical equipment and supplies | ||
| Durable medical equipment (e.g. wheelchairs, oxygen) | 19%–20% coinsurance(authorization required) | 30% coinsurance |
| Prosthetics (e.g. braces, artificial limbs) | 0%–20% coinsurance(authorization required) | 0%–40% coinsurance |
| Medical supplies | 0%–20% coinsurance(authorization required) | 0%–30% coinsurance |
| Diabetes supplies | 0%–20% coinsurance(authorization required) | 20%–30% coinsurance |
| Diabetic therapeutic shoes or inserts | $0 copay(authorization required) | 20% coinsurance |
| Chiropractic, acupuncture and foot care | ||
| Chiropractic (Medicare-covered) | $15 copay(authorization required) | $15 copay |
| Routine chiropractic care | Not covered | — |
| Acupuncture | Not covered | — |
| Foot exams and treatment (Medicare-covered) | $45 copay(authorization required) | $45 copay |
| Routine foot care | Not covered | — |
| Dental? | ||
| Medicare-covered dental services | $45 copay(authorization required) | $45 copay |
| Preventive dental plan limit | $250 plan limit every year | — |
| Oral exams | $0 copay | $0 copay |
| Cleanings | $0 copay | $0 copay |
| Fluoride treatment | $0 copay | $0 copay |
| Dental x-rays | $0 copay | $0 copay |
| Other diagnostic dental services | $0 copay | $0 copay |
| Other preventive dental services | $0 copay | $0 copay |
| Restorative services (fillings, crowns) | $0 copay | $0 copay |
| Endodontics (root canals) | $0 copay | $0 copay |
| Periodontics (gum disease) | $0 copay | $0 copay |
| Dentures and other removable prosthodontics | $0 copay | $0 copay |
| Maxillofacial prosthetics | Not covered | — |
| Implants | Not covered | — |
| Bridges and other fixed prosthodontics | $0 copay | $0 copay |
| Oral and maxillofacial surgery | $0 copay | $0 copay |
| Orthodontics | Not covered | — |
| Adjunctive general services | $0 copay | $0 copay |
| Vision? | ||
| Eye exam (Medicare-covered) | $0–$20 copay(authorization required) | $0–$20 copay |
| Routine eye exam | $0 copay(authorization required, limits apply) | $0 copay |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) | — |
| Eyewear plan limit | $200 plan limit every year | — |
| Contact lenses | $0 copay(limits apply) | $0 copay |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) | $0 copay |
| Eyeglass lenses | $0 copay(limits apply) | $0 copay |
| Eyeglass frames | $0 copay(limits apply) | $0 copay |
| Eyewear upgrades | $0 copay(limits apply) | $0 copay |
| Hearing? | ||
| Hearing exam (Medicare-covered) | $45 copay(authorization required) | $45 copay |
| Routine hearing exam | $0 copay(authorization required, limits apply) | $0 copay |
| Hearing aid fitting and evaluation | $0 copay(authorization required) | $0 copay |
| Hearing aids (all types) | $599–$899 copay(limits apply) | $599–$899 copay |
| Hearing aids, inner ear | Not covered | — |
| Hearing aids, outer ear | Not covered | — |
| Hearing aids, over the ear | Not covered | — |
| Medicare Part B drugs | ||
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) | 40% coinsurance |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 40% coinsurance |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 0%–40% coinsurance |
| Other extra benefits? | ||
| Over-the-counter (OTC) allowance | Not covered | — |
| Meals after a hospital stay or for a chronic condition | Not covered | — |
| Fitness benefit | $0 copay | $0 copay |
| Health education | $0 copay | $0 copay |
| Nutritional / dietary benefit | $0 copay | $0 copay |
| Extra smoking and tobacco cessation counseling | Not covered | — |
| Enhanced disease management | Not covered | — |
| Telemonitoring | Not covered | — |
| Remote access technologies (web/phone, nurse line) | Not covered | — |
| Home and bathroom safety devices | $0 copay | 30% coinsurance |
| Counseling services | Not covered | — |
| In-home safety assessment | Not covered | — |
| Personal emergency response system (PERS) | Not covered | — |
| Medical nutrition therapy | Not covered | — |
| Post-discharge in-home medication reconciliation | Not covered | — |
| Re-admission prevention | Not covered | — |
| Wigs for hair loss from chemotherapy | Not covered | — |
| Weight management programs | $0 copay | $0 copay |
| Alternative therapies | $0 copay | $0 copay |
| Therapeutic massage | Not covered | — |
| Adult day health services | Not covered | — |
| Home-based palliative care | Not covered | — |
| In-home support services | Not covered | — |
| Support for caregivers | Not covered | — |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $3.00 |
| Tier 3 | 21% |
| Tier 4 | 25% |
| Tier 5 | 25% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $3.00 | $3.00 | $3.00 | $9.00 | $9.00 | $7.50 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $3.00 | $3.00 | $3.00 | $9.00 | $9.00 | $7.50 |
| Tier 3: Preferred Brand | 21% | 21% | 21% | 21% | 21% | 21% |
| Tier 4: Non-Preferred Drug | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 82 other GA counties
- Appling
- Atkinson
- Bacon
- Baldwin
- Barrow
- Ben Hill
- Berrien
- Brooks
- Butts
- Candler
- Catoosa
- Charlton
- Chattahoochee
- Chattooga
- Clinch
- Colquitt
- Cook
- Crawford
- Dade
- Dawson
- Dodge
- Dooly
- Echols
- Elbert
- Emanuel
- Evans
- Fannin
- Franklin
- Gilmer
- Glascock
- Greene
- Haralson
- Harris
- Hart
- Heard
- Irwin
- Jasper
- Jeff Davis
- Jefferson
- Johnson
- Jones
- Lamar
- Lanier
- Lowndes
- Lumpkin
- Macon
- Meriwether
- Monroe
- Montgomery
- Morgan
- Murray
- Muscogee
- Oconee
- Oglethorpe
- Peach
- Pike
- Polk
- Pulaski
- Putnam
- Rabun
Benefits in plain text
DEVOTED CHOICE GIVEBACK 005 GA (PPO) (H5453-005-0) is a 2026 PPO Medicare Advantage plan offered by Devoted Health, available to residents of Hancock County, GA.
The monthly premium is $0.00 (Part C and Part D together).
The plan reduces the member's Medicare Part B premium by $164.10 a month (a "giveback"); the Part B premium itself must still be paid.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
Its in-network out-of-pocket maximum is $9,250.00.
The combined in- and out-of-network out-of-pocket maximum is $10,000.00.
The drug deductible is $605.00. Tier 1 and 2 exempt.
The plan's formulary lists 3,377 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $3.00; tier 3: 21%; tier 4: 25%; tier 5: 25%.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.