DEVOTED CHOICE MA ONLY 003 GA (PPO) Medicare Advantage Plan H5453-003 • 2027
CMS Rating:
(4.0 out of 5 stars*)
- Monthly Premium
- $0.00Plus Part B premium.
- Medical Deductible
- $0.00
- Maximum Out-of-Pocket
- $9250.00In-network
- Part B Giveback
- −$184.70 reduction
- Prescription Coverage
- Not Included
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- See List
- Total Enrollment
- 2,022 beneficiaries
Last update:
DEVOTED CHOICE MA ONLY 003 GA (PPO) Introduction
This Medicare Advantage PPO plan, DEVOTED CHOICE MA ONLY 003 GA, is offered by Devoted Health and uses a Preferred Provider Organization (PPO) provider network. It comes without prescription drug coverage. For the 2027 plan year, the monthly premium is $0.00, the medical deductible is $0.00, and the in-network maximum out-of-pocket is $9250.00. The plan is identified by CMS Plan ID H5453-003.
Plan Benefits
DEVOTED CHOICE MA ONLY 003 GA includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The tables below outline the most common in-network out-of-pocket costs associated with plan H5453-003.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | In-network: $0 copay Out-of-network: $15 copay |
In-network: $0 copay Out-of-network: $15 copay |
| Specialist | In-network: $50 copay Out-of-network: $60 copay |
In-network: $50 copay Out-of-network: $50 copay |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay |
| Telehealth benefit | In-network: $0-$50 copay | In-network: $0-$50 copay |
| Routine chiropractic | Not covered | Not covered |
| Fitness benefits | Coming soon | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Health education | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Counseling services | Not covered | Not covered |
| Over-the-counter drug benefits | Not covered | Not covered |
| Health transportation (non-emergency) | Coming soon | Not covered |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | In-network: $25-$300 copay Out-of-network: $35-$350 copay |
In-network: $0-$300 copay Out-of-network: $0-$300 copay |
| Lab services | In-network: $0-$50 copay, 20% coinsurance Out-of-network: $10-$60 copay, 20% coinsurance |
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-$85 copay |
In-network: $0-$75 copay Out-of-network: $0-$75 copay |
| Diagnostic tests and procedures | In-network: $0-$95 copay Out-of-network: $0-$105 copay |
In-network: $0-$95 copay Out-of-network: $0-$95 copay |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | $115 copay | $115 copay |
| Worldwide emergency care | Coming soon | $115 copay |
| Urgent care | $0-$40 copay | $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 |
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 $221 per day for days 21-100 Out-of-network: 40% per stay |
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 |
In-network: $0-$350 copay Out-of-network: $0-$350 copay |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | In-network: $50 copay Out-of-network: $60 copay |
In-network: $50 copay Out-of-network: $50 copay |
| Outpatient group therapy | In-network: $50 copay Out-of-network: $60 copay |
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 |
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 |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | In-network: $50 copay Out-of-network: $60 copay |
In-network: $50 copay Out-of-network: $50 copay |
| Occupational therapy | In-network: $35 copay Out-of-network: $45 copay |
In-network: $35 copay Out-of-network: $35 copay |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: 0%-20% coinsurance Out-of-network: 20%-23% coinsurance |
| Durable medical equipment | In-network: 20% coinsurance Out-of-network: 50% coinsurance |
In-network: 20% coinsurance Out-of-network: 23% coinsurance |
| Prosthetics | In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | In-network: 0%-20% coinsurance Out-of-network: 40% coinsurance |
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 |
In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
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 |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Cleaning | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Periodontics | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Endodontics | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
In-network: 0%-50% coinsurance Out-of-network: 0%-50% coinsurance |
| Restorative services | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
In-network: 0%-50% coinsurance Out-of-network: 0%-50% coinsurance |
| Implant services | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
Not covered |
| Orthodontics | Not covered | Not covered |
| Oral/Maxillofacial surgery | In-network: 50% coinsurance Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Contact lenses | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
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 |
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 |
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 |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Upgrades | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | In-network: $0 copay Out-of-network: $35 copay |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Fitting/evaluation | In-network: $0 copay Out-of-network: $35 copay |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Prescription hearing aids | In-network: $599-$899 copay Out-of-network: 90% coinsurance |
In-network: $599-$899 copay Out-of-network: $599-$899 copay |
| OTC hearing aids | Not covered | Not covered |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Not covered | Not covered |
| Home-based palliative care | Not covered | Not covered |
| Personal emergency response system | Coming soon | Not covered |
| Weight management programs | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Wigs for chemotherapy-related hair loss | Coming soon | Not covered |
| Alternative therapies | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Massage therapy | Not covered | Not covered |
| Home/bathroom safety devices | In-network: $0 copay Out-of-network: 50% coinsurance |
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 Performance Ratings (Contract ID: H5453)
The Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (Part C) and Part D prescription drug plans each year using a 5-star system. These ratings measure plan performance in areas such as preventive care, management of chronic conditions, and member experience.
| CMS Measure | Star Rating |
|---|---|
| 2027 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 |
Contact Information for Devoted Health
- Website
- Devoted Health Plan Page
- Providers
- Devoted Health Providers Page
- Formulary
- Devoted Health Formulary Page
- Pharmacy
- Devoted Health Pharmacy Page
- New Member Health Plan Help
- (844)978-2770
- New Member Health Plan TTY
- 711
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Plan Availability
DEVOTED CHOICE MA ONLY 003 GA (H5453-003-0) is available in the following locations:
Georgia Counties Served
- Appling
- Atkinson
- Bacon
- Baldwin
- Barrow
- Bartow
- Ben Hill
- Berrien
- Brooks
- Bryan
- Bulloch
- Burke
- Butts
- Camden
- Candler
- Catoosa
- Charlton
- Chatham
- Chattahoochee
- Chattooga
- Cherokee
- Clayton
- Clinch
- Cobb
- Colquitt
- Columbia
- Cook
- Coweta
- Crawford
- Dade
- Dawson
- Dekalb
- Dodge
- Dooly
- Douglas
- Echols
- Effingham
- Elbert
- Emanuel
- Evans
- Fannin
- Fayette
- Forsyth
- Franklin
- Fulton
- Gilmer
- Glascock
- Greene
- Gwinnett
- Hancock
- Haralson
- Harris
- Hart
- Heard
- Henry
- Irwin
- Jasper
- Jeff Davis
- Jefferson
- Jenkins
- Johnson
- Jones
- Lamar
- Lanier
- Lincoln
- Long
- Lowndes
- Lumpkin
- Macon
- Mcduffie
- Mcintosh
- Meriwether
- Monroe
- Montgomery
- Morgan
- Murray
- Muscogee
- Oconee
- Oglethorpe
- Paulding
- Peach
- Pickens
- Pike
- Polk
- Pulaski
- Putnam
- Rabun
- Richmond
- Rockdale
- Screven
- Spalding
- Stephens
- Talbot
- Taliaferro
- Tattnall
- Taylor
- Telfair
- Thomas
- Tift
- Towns
- Treutlen
- Twiggs
- Upson
- Walker
- Walton
- Warren
- Washington
- Wayne
- Wheeler
- White
- Wilcox
- Wilkes
- Wilkinson
Frequently Asked Questions
Here are some of the most frequently asked questions about this plan (click to open).
Frequently Asked Questions About DEVOTED CHOICE MA ONLY 003 GA (PPO)
What is the monthly premium for DEVOTED CHOICE MA ONLY 003 GA (PPO)?
For 2027, the monthly premium is $0.00. Medicare Part B premiums apply in addition to this amount.
What is the in-network MOOP for plan H5453-003?
The 2027 in-network MOOP is $9250.00. Once this limit is reached, covered in-network costs are fully covered.
What is the total enrollment for plan H5453-003?
The plan has 2,022 enrolled beneficiaries according to CMS.
What is the Part D deductible for plan H5453-003?
The Part D deductible is $0.00.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Devoted Health (official source) | http://www.devoted.com | October 4, 2026 |
| Medicare.gov | Compare types of Medicare Advantage Plans | 25 May, 2025 |
| AARP.org | The Big Choice: Original Medicare vs. Medicare Advantage | 25 May, 2025 |
| Medicare.gov | Explore your Medicare coverage options | 25 May, 2025 |
MedicarePlans.com is an independent, non-government informational resource and is not affiliated with or endorsed by the U.S. Government or the federal Medicare program.
Data provenance is documented in accordance with the U.S. Core Data for Interoperability (USCDI) Provenance standard.
Page content independently curated and maintained by David W. Bynon, Editorial Steward, using a standardized, data-driven methodology for accurate, non-commercial Medicare plan interpretation and resolution.