- Entity
- plan:H5453-004-0
- Digest
- 2026-cms-snp-plan
- Source URL
- https://www.medicareplans.com/medicare-advantage/plan/H5453-004-0/
- Glossary Scope
- cms_landscape
- Fragment Scope
- semantic-digest
- Method
- https://webmem.com/protocol/serialization/html/
- fragment-H5453-004-0-performance
- CMS Plan ID
- All MA/MAPD and PDP plans have a CMS plan ID consisting of a contract ID, plan ID, and segment ID formatted like: H1234-001-0.
- Value
- H5453-004-0
- Derived
- true
- Contract Year
- The calendar year in which the plan's benefits, premiums, and rules are effective as defined by CMS.
- Value
- 2026
- Derived
- false
- Contract Category Type
- The CMS-assigned contract type for the plan, such as MA, MAPD, SNP, or PDP, which indicates the scope of services and population the contract is designed to serve.
- Value
- MA-PD
- Derived
- false
- Contract ID
- The unique contract ID assigned to a carrier by CMS. All plans have a contract ID.
- Value
- H5453
- Derived
- false
- Plan ID
- The unique plan ID within a CMS contract.
- Value
- 004
- Derived
- false
- Segment ID
- A segment ID is used to identify specific geographic market segments or subdivisions for variations in benefits, costs, and premiums.
- Value
- 0
- Derived
- false
- Parent Organization Name
- The legal parent company that owns the Medicare Advantage contract and is ultimately responsible for the plan’s administration.
- Value
- Devoted Health, Inc.
- Derived
- false
- Organization Marketing Name
- The publicly marketed name of the Medicare Advantage plan carrier as displayed to consumers, which may differ from the legal or corporate entity name.
- Value
- Devoted Health
- Derived
- false
- Organization Type
- A descriptive label that classifies the Medicare plan contract type in plain language, such as Local HMO, Regional PPO, or SNP.
- Value
- Local CCP
- Derived
- true
- Plan Name
- The official name of the Medicare Advantage plan as listed in CMS source data.
- Value
- DEVOTED CHOICE 004 GA (PPO)
- Derived
- false
- Plan Type
- The type of Medicare plan, such as PDP, Regional PPO, HMO-POS, HMO D-SNP, which determines how the plan manages care and provider access.
- Value
- PPO
- Derived
- false
- Special Needs Plan (SNP) Indicator
- Indicates whether the plan is a Special Needs Plan (SNP), designed to serve people with specific diseases, dual eligibility, or institutional needs.
- Value
- No
- Derived
- false
- SNP Type
- Specifies the type of Special Needs Plan, such as D-SNP for dual-eligible individuals, C-SNP for chronic conditions, or I-SNP for institutional care.
- Value
- Not Applicable
- Derived
- false
- Part D Coverage Indicator
- Indicates whether the Medicare Advantage plan includes Part D prescription drug coverage.
- Value
- Yes
- Derived
- false
- Drug Benefit Category
- Specifies whether the plan’s drug benefit is defined as basic, enhanced, or other CMS-classified categories.
- Value
- Enhanced
- Derived
- false
- Drug Benefit Type
- Specifies the delivery structure of the plan’s drug benefit, such as defined standard, actuarially equivalent, or enhanced alternative.
- Value
- Enhanced Alternative
- Derived
- false
- Voluntary De Minimis
- Indicates whether the plan participates in the voluntary de minimis policy, allowing small premium differences without disqualifying LIS benchmark eligibility.
- Value
- No
- Derived
- false
- Part D Basic Premium Benchmark
- The CMS-calculated benchmark for basic Part D premiums used to determine Low-Income Subsidy (LIS) eligibility thresholds.
- Value
- Not Applicable
- Derived
- false
- LIS Auto-Enrollment Eligible
- Indicates whether the plan is eligible for automatic enrollment of Low-Income Subsidy (LIS) beneficiaries by CMS.
- Value
- Not Applicable
- Derived
- false
- Drug Tiers with No Deductible
- Indicates which drug tiers are excluded from the plan’s Part D deductible, allowing members to access medications without paying the deductible first.
- Value
- Yes
- Derived
- false
- Part D Deductible
- The annual amount a member must pay out of pocket for Part D drugs before the plan begins to pay.
- Value
- 370.00
- Derived
- false
- Part D Basic Premium
- The portion of the plan's monthly premium that covers the standard Part D drug benefit.
- Value
- -31.00
- Derived
- false
- Part D Supplemental Premium
- The monthly premium amount for any supplemental drug coverage offered beyond the standard Part D benefit.
- Value
- 31.00
- Derived
- false
- Part D Total Premium
- The total monthly premium for the Part D plan, including both the basic and any supplemental components.
- Value
- 0.00
- Derived
- true
- Low Income Premium Subsidy (LIPS) Amount
- The amount of monthly premium subsidized by CMS for Low-Income Subsidy (LIS) eligible members enrolled in the plan.
- Value
- 25.42
- Derived
- false
- Part D LIPS (CMS Pays)
- The total amount CMS pays on behalf of LIS-eligible enrollees to cover premium costs under the Low-Income Subsidy program.
- Value
- 0.00
- Derived
- false
- Part D Low Income Beneficiary Premium Amount
- The amount that a Low-Income Subsidy (LIS) beneficiary is responsible for paying after CMS premium subsidies have been applied.
- Value
- 0.00
- Derived
- true
- Part D Out-of-Pocket (OOP) Threshold
- The total amount a member must spend on covered Part D drugs in a calendar year before entering the catastrophic coverage phase.
- Value
- 2100.00
- Derived
- false
- Part C Premium
- The monthly premium a member pays for Medicare Advantage (Part C) coverage, excluding prescription drug (Part D) premiums.
- Value
- $0.00
- Derived
- false
- Monthly Consolidated Premium (Part C + D)
- The total monthly premium a member pays for the Medicare Advantage plan, including both Part C and Part D coverage.
- Value
- $0.00
- Derived
- true
- In-Network Maximum Out-of-Pocket (MOOP) Amount
- The maximum amount a member will pay out of pocket for in-network Medicare-covered services during the plan year, after which the plan pays 100%.
- Value
- Derived
- false
- Record Checksum
- Checksum value associated with this published plan record.
- Value
- VXQ-731-H5453-004-0
- Derived
- true
- Entity
- contract:H5453
- Digest
- 2026-cms-part-c-and-d-performance
- Source URL
- https://www.medicareplans.com/medicare-advantage/plan/H5453-004-0/
- Glossary Scope
- cms_performance
- Fragment Scope
- semantic-digest
- Method
- https://webmem.com/protocol/serialization/html/
- fragment-H5453-004-0-landscape
- Overall Star Rating
- The overall CMS star rating for the plan, based on quality and performance across all measured domains.
- Value
- Plan has not been rated by CMS
- Unit
- stars
- Derived
- false
- Staying Healthy Measure
- Includes preventive screenings, vaccines, and wellness checks that help members stay healthy.
- Value
- Plan too new to be measured
- Unit
- stars
- Derived
- false
- Managing Chronic Conditions Measure
- Evaluates how effectively the plan helps members manage chronic health conditions like diabetes, COPD, or hypertension.
- Value
- Plan too new to be measured
- Unit
- stars
- Derived
- false
- Member Experience Measure (Health Plan)
- Captures what members say about their experience with the health plan.
- Value
- Plan too new to be measured
- Unit
- stars
- Derived
- false
- Plan Complaints Measure
- Tracks member complaints and changes in the plan’s performance over time.
- Value
- Plan too new to be measured
- Unit
- stars
- Derived
- false
- Health Plan Customer Service Measure
- Measures how well the plan handles member appeals and customer inquiries.
- Value
- Plan too new to be measured
- Unit
- stars
- Derived
- false
- Drug Plan Customer Service Measure
- Rates the drug plan’s customer service and availability of foreign language and TTY services.
- Value
- 5
- Unit
- stars
- Derived
- false
- Drug Plan Complaints Measure
- Tracks complaints about the drug plan and trends in plan improvement.
- Value
- Plan too new to be measured
- Unit
- stars
- Derived
- false
- Member Experience Measure (Drug Plan)
- Reflects satisfaction with the drug plan’s benefits and service.
- Value
- Plan too new to be measured
- Unit
- stars
- Derived
- false
- Drug Safety and Pricing Accuracy Measure
- Assesses how accurately the drug plan prices medications and ensures safe usage.
- Value
- Plan too new to be measured
- Unit
- stars
- Derived
- false
DEVOTED CHOICE 004 GA (PPO) Medicare Advantage Plan H5453-004 • 2026
The Medicare Advantage plan identified by CMS Plan ID H5453-004 (DEVOTED CHOICE 004 GA) is a PPO Part C plan offered by Devoted Health for the 2026 plan year. It uses a Preferred Provider Organization (PPO) provider network and comes with drug coverage (Part D prescriptions).
DEVOTED CHOICE 004 GA Overview
Plan Overview for
H5453-004-0
|
|
|---|---|
| CMS Plan ID: |
H5453-004-0
|
| Plan Type: | PPO |
| Plan Year: | 2026 |
| Monthly Premium: |
$0.00
Plus your Medicare Part B premium. |
| Medical Deductible: | $0.00 |
| Maximum Out-of-Pocket: | $8650.00 (In-Network) |
| Part B Give Back: | Not offered |
| Prescription Drug Coverage: | Enhanced, $370.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Service Area: | See List |
| Enrollment (Nationwide): | 1,345 beneficiaries |
| Provided By: | Devoted Health |
Plan Availability
DEVOTED CHOICE 004 GA (H5453-004-0) is available in the following locations (click to open):
Plan Overview for DEVOTED CHOICE 004 GA
This Medicare Advantage MAPD PPO plan combines hospital, medical, and prescription drug coverage and allows access to Medicare-approved providers. The monthly premium is $0.00, and the plan includes Medicare Part A and Part B benefits along with integrated prescription drug coverage. The annual Part D deductible is $370.00.
Primary care visits have a $0 copay | Out-of-network: $15 copay, while specialist visits come with a $30 copay | Out-of-network: $30 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 $8650.00. After 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 H5453-004. Cost-sharing details for key services are provided below.
Cost Sharing Expenses
DEVOTED CHOICE 004 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 H5453-004.
Certain preventive services are covered 100% by DEVOTED CHOICE 004 GA as a Part B benefit.
Prescription Drug Coverage
DEVOTED CHOICE 004 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.
| Basic Part D Premium: | $-31.00 |
|---|---|
| Supplemental Part D Premium: | $31.00 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | $25.42 |
| Low-Income Premium Subsidy Paid by CMS: | $0.00 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $370.00 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 004 GA may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | Coming soon |
| Generic | $0.00 copay | Coming soon |
| Preferred Brand | 19% coinsurance | Coming soon |
| Non-Preferred Drug | 25% coinsurance | Coming soon |
| Specialty Tier | 28% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS Star Ratings
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 |
|---|---|
| 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 |
How much does plan H5453-004 cost per month?
The plan’s monthly premium is $0.00 for 2026. The Part B premium is not included.
What is the annual out-of-pocket maximum (MOOP) for this plan?
The annual in-network MOOP is $8650.00 for 2026. After this limit is reached, covered in-network services are fully paid.
What is the CMS star rating for DEVOTED CHOICE 004 GA?
The 2026 CMS star rating for DEVOTED CHOICE 004 GA is ★0.0 out of 5.
What is the current enrollment for DEVOTED CHOICE 004 GA?
The plan has 1,345 enrolled beneficiaries according to CMS.
What is the prescription drug deductible for 2026?
For 2026, the prescription drug deductible is $370.00.
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.
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | September 8, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | September 8, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | September 8, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | September 8, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Devoted Health (official source) | http://www.devoted.com | October 13, 2025 |
| Medicare.gov | Compare types of Medicare Advantage Plans | 25 May, 2025 |
| NCOA.org | 5 Steps to Choosing the Right Medicare Plan for You | 25 May, 2025 |
| Medicare.gov | Compare Original Medicare & Medicare Advantage | 25 May, 2025 |
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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.