DEVOTED CHOICE MA ONLY 003 GA (PPO) Medicare Advantage Plan H5453-003 • 2026 • Clayton County, GA

DEVOTED CHOICE MA ONLY 003 GA Overview

Coverage Overview for DEVOTED CHOICE MA ONLY 003 GA

As a Medicare Advantage PPO plan, DEVOTED CHOICE MA ONLY 003 GA covers Medicare Part A and Part B services and allows access to Medicare-approved providers. The monthly premium is $0.00, with lower costs when using in-network providers.

Primary care visits have a $0 copay | Out-of-network: $15 copay, specialist visits come with a $50 copay | Out-of-network: $50 copay, urgent care services carry a $0-$40 copay, and ambulance transportation is $0-$350 copay | Out-of-network: $0-$350 copay. These expenses apply toward the annual maximum out-of-pocket (MOOP) limit of $9250.00. After this limit is reached, in-network services are fully covered.

This plan is registered with CMS under Plan ID H5453-003. Cost-sharing details are outlined below.

Cost-Sharing Overview

Cost-sharing for DEVOTED CHOICE MA ONLY 003 GA includes out-of-pocket expenses for covered healthcare services. The table below provides a summary of typical in-network out-of-pocket costs for plan H5453-003.

Certain preventive services are covered 100% by DEVOTED CHOICE MA ONLY 003 GA as a Part B benefit.

Prescription Drug Coverage

This plan does not include a Medicare Part D plan for prescriptions.

CMS 5-Star Ratings

CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.