DEVOTED CHOICE MA ONLY 003 GA (PPO)
Medicare Advantage Plan H5453-003 • 2026 • Evans County, GA
DEVOTED CHOICE MA ONLY 003 GA (PPO) Medicare Advantage Plan H5453-003 • 2026 • Evans County, GA
DEVOTED CHOICE MA ONLY 003 GA is a Medicare Advantage PPO plan offered by Devoted Health for the 2026 plan year. It is identified by CMS Plan ID H5453-003 and uses a Preferred Provider Organization (PPO) provider network. The plan comes without prescription drug coverage.
DEVOTED CHOICE MA ONLY 003 GA Overview
Plan Overview for H5453-003-0 |
|
|---|---|
| CMS Plan ID: | H5453-003-0 |
| Plan Type: | PPO |
| Plan Year: | 2026 |
| Monthly Premium: | $0.00 Plus your Medicare Part B premium. |
| Medical Deductible: | $0.00 |
| Maximum Out-of-Pocket: | $9250.00 (In-Network) |
| Part B Give Back: | −$184.70 reduction |
| Prescription Drug Coverage: | Not Included |
| Additional Benefits: | Dental, Vision, Hearing |
| Service Area: | Evans County, GA |
| Enrollment (Nationwide) | 1,785 beneficiaries |
| Enrollment (CMS – Local) | 0 beneficiaries in Evans County |
| Provided By: | Devoted Health |
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, lab services cost {lab_services_cost}, 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 {title_plan_id}. 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.
This section outlines in-network costs for primary care and specialist office visits, along with related preventive services.
| Covered Service | In-Network Cost |
|---|---|
| Primary: | In-network: $0 copay | Out-of-network: $15 copay |
| Specialist: | In-network: $50 copay | Out-of-network: $50 copay |
This section outlines in-network costs for preventive and wellness services included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Annual wellness exam: | In-network: $0 copay |
| Telehealth benefit: | In-network: $0-$50 copay |
| Routine chiropractic: | Not covered |
| Fitness benefits: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Health education: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Counseling services: | Not covered |
| Over-the-counter drug benefits: | Not covered |
| Health transportation (non-emergency): | Not covered |
This section outlines in-network costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Covered Service | In-Network Cost |
|---|---|
| Diagnostic radiology services: | In-network: $0-$300 copay | Out-of-network: $0-$300 copay |
| Lab services: | In-network: $0-$40 copay | Out-of-network: $0-$40 copay, 20% coinsurance |
| Outpatient x-rays: | In-network: $0-$75 copay | Out-of-network: $0-$75 copay |
| Diagnostic tests and procedures: | In-network: $0-$95 copay | Out-of-network: $0-$95 copay |
This section outlines in-network costs for emergency services, urgent care, ambulance transportation, inpatient hospital stays, and skilled nursing facility care.
| Covered Service | In-Network Cost |
|---|---|
| Emergency room care: | $115 copay |
| Worldwide emergency care: | $115 copay |
| Urgent care: | $0-$40 copay |
| Inpatient hospital care: | In-network: | Tier 1 | $425 per day for days 1-4 | $0 per day for days 5-90 | $0 per stay | Out-of-network: | $425 per day for days 1-4 | $0 per day for days 5-90 | $0 per stay |
| Skilled Nursing Facility: | In-network: | Tier 1 | $0 per day for days 1-20 | $218 per day for days 21-100 | Out-of-network: | 26% per stay |
| Ground ambulance: | In-network: $0-$350 copay | Out-of-network: $0-$350 copay |
This section outlines in-network costs for mental health services, including outpatient therapy and inpatient psychiatric care.
| Covered Service | In-Network Cost |
|---|---|
| Outpatient individual therapy: | In-network: $50 copay | Out-of-network: $50 copay |
| Outpatient group therapy: | In-network: $50 copay | Out-of-network: $50 copay |
| Inpatient psychiatric hospital care: | In-network: | Tier 1 | $425 per day for days 1-4 | $0 per day for days 5-90 | $0 per stay | Out-of-network: | $425 per day for days 1-4 | $0 per day for days 5-90 | $0 per stay |
This section outlines in-network costs for rehabilitation services, including physical therapy, speech and language therapy, and occupational therapy.
| Covered Service | In-Network Cost |
|---|---|
| Physical therapy and speech and language therapy: | In-network: $50 copay | Out-of-network: $50 copay |
| Occupational therapy: | In-network: $35 copay | Out-of-network: $35 copay |
This section outlines in-network costs for medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Covered Service | In-Network Cost |
|---|---|
| Diabetes supplies: | In-network: 0%-20% coinsurance | Out-of-network: 20%-23% coinsurance |
| Durable medical equipment: | In-network: 20% coinsurance | Out-of-network: 23% coinsurance |
| Prosthetics: | In-network: 0%-20% coinsurance | Out-of-network: 0%-40% coinsurance |
This section outlines in-network cost sharing for chemotherapy and other Medicare Part B-covered drugs.
| Covered Service | In-Network Cost |
|---|---|
| Chemotherapy: | In-network: 0%-20% coinsurance | Out-of-network: 40% coinsurance |
| Other Part B drugs (Medicare-covered): | In-network: 0%-20% coinsurance | Out-of-network: 0%-40% coinsurance |
This section outlines in-network cost sharing for dental services, including preventive care, exams, x-rays, cleanings, and comprehensive dental procedures.
| Covered Service | In-Network Cost |
|---|---|
| Oral exam: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Dental x-rays: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Cleaning: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Periodontics: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Endodontics: | In-network: 0%-50% coinsurance | Out-of-network: 0%-50% coinsurance |
| Restorative services: | In-network: 0%-50% coinsurance | Out-of-network: 0%-50% coinsurance |
| Implant services: | Not covered |
| Orthodontics: | Not covered |
| Oral/Maxillofacial surgery: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
This section outlines in-network cost sharing for vision services, including eye exams, eyeglasses, and contact lenses.
| Covered Service | In-Network Cost |
|---|---|
| Routine eye exam: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Contact lenses: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass frames only: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass lenses only: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglasses (frames & lenses): | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Upgrades: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
This section outlines in-network cost sharing for hearing-related services, including exams, fittings, and hearing aids.
| Covered Service | In-Network Cost |
|---|---|
| Hearing exam: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Fitting/evaluation: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Prescription hearing aids: | In-network: $599-$899 copay | Out-of-network: $599-$899 copay |
| OTC hearing aids: | Not covered |
This section outlines in-network cost sharing for additional and special needs services that may be included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Adult day health services: | Not covered |
| Home-based palliative care: | Not covered |
| Personal emergency response system: | Not covered |
| Weight management programs: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Wigs for chemotherapy-related hair loss: | Not covered |
| Alternative therapies: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Massage therapy: | Not covered |
| Home/bathroom safety devices: | In-network: $0 copay | Out-of-network: 23% coinsurance |
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.
| CMS Measure | Star Rating |
|---|---|
| 2026 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | Plan too new to be measured |
| Managing Chronic (Long Term) Conditions | Plan too new to be measured |
| Member Experience with Health Plan | Plan too new to be measured |
| Complaints and Changes in Plans Performance | Plan too new to be measured |
| Health Plan Customer Service | Plan too new to be measured |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | Plan too new to be measured |
| Member Experience with the Drug Plan | Plan too new to be measured |
| Drug Safety and Accuracy of Drug Pricing | Plan too new to be measured |
What is the monthly premium for DEVOTED CHOICE MA ONLY 003 GA (PPO)?
The 2026 monthly premium is $0.00. The Medicare Part B premium is paid separately.
What is the in-network MOOP for plan H5453-003?
For 2026, the in-network maximum out-of-pocket is $9250.00. The plan pays 100% of covered in-network services beyond this amount.
What is the total enrollment for plan H5453-003?
Total enrollment is 1,785 beneficiaries based on the latest CMS data.
What is the Part D deductible for plan H5453-003?
The plan’s Part D deductible is $0.00, applied to covered prescription drug costs.
Contact Information for Devoted Health
| Contact Type | Details |
|---|---|
| Website: | Devoted Health Plan Page |
| New Members: | 1-844-978-2770 |
| Existing Members: | 1-800-338-6833 |
| Plan Address: | Devoted Health | PO Box 211037 | Eagan, MN 55121 |
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at medicare.gov.
- CMS.gov, Landscape Source Files — Last accessed May 2, 2026
- CMS.gov, Medicare Part C & D Performance — Last accessed May 2, 2026
- CMS.gov, Plan Benefits Package — Last accessed May 2, 2026
- CMS.gov, Monthly Enrollment by Contract/Plan/State/County — Last accessed May 2, 2026
Data sources and methodology documentation..
- Devoted Health (official source), http://www.devoted.com — Last accessed October 13, 2025
- CMS.gov, "Medicare Advantage Plan Fact Sheet" — Last accessed 25 May, 2025
- AARP.org, "The Big Choice: Original Medicare vs. Medicare Advantage" — Last accessed 25 May, 2025
- Medicare.gov, "Your coverage options" — Last accessed 25 May, 2025
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