DEVOTED CHOICE GIVEBACK 002 GA (PPO) Medicare Advantage Plan H5453-002 • 2026 • Clayton County, GA

DEVOTED CHOICE GIVEBACK 002 GA Overview

Plan Details for DEVOTED CHOICE GIVEBACK 002 GA

This Medicare Advantage MAPD PPO plan includes Medicare Part A and Part B services along with integrated prescription drug coverage. The monthly premium is $0.00, and the plan allows access to Medicare-approved providers, with lower costs when using in-network providers. The annual Part D deductible is $605.00.

Primary care visits have a $0 copay | Out-of-network: $15 copay, and specialist visits come with a $45 copay | Out-of-network: $45 copay. Urgent care services carry a $0-$40 copay, and ground ambulance transportation is $0-$315 copay | Out-of-network: $0-$315 copay. These costs apply toward the annual maximum out-of-pocket (MOOP) limit of $9250.00. Once this limit is reached, in-network services are fully covered for the remainder of the year.

This plan is listed by CMS under Plan ID H5453-002. Cost-sharing details are provided below.

Cost Sharing Expenses

DEVOTED CHOICE GIVEBACK 002 GA has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The table below details the most common in-network out-of-pocket expenses for plan H5453-002.

Certain preventive services are covered 100% by DEVOTED CHOICE GIVEBACK 002 GA as a Part B benefit.

Prescription Drug Coverage

DEVOTED CHOICE GIVEBACK 002 GA includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.

This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.

Prescription Drug Plan Premium

The Part D prescription drug plan premium is included in the overall Medicare Special Needs Plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.

For more details, visit the Social Security Extra Help program .

Prescription Drug Plan Deductible

This plan has a $605.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Devoted Health starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, DEVOTED CHOICE GIVEBACK 002 GA may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

Medicare Plan Star Ratings

Medicare Advantage (Part C) and Part D plans are rated each year by CMS on a 5-star scale. Ratings summarize plan performance across clinical care and member experience measures.