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Devoted LIBERTY CHOICE Georgia (PPO)

H5453 - 003 - 0
Plan Not Rated

Devoted LIBERTY CHOICE Georgia (PPO) is a Medicare Advantage Plan by Devoted Health.

This page features plan details for 2025 Devoted LIBERTY CHOICE Georgia (PPO) H5453 – 003 – 0 available in Georgia.

Locations

Devoted LIBERTY CHOICE Georgia (PPO) is offered in the following locations.

Bartow County, Georgia
Bryan County, Georgia
Bulloch County, Georgia

Click to see more locations

Plan Overview

Devoted LIBERTY CHOICE Georgia (PPO) offers the following coverage and cost-sharing.

Insurer:Devoted Health
Health Plan Deductible:$0
MOOP:$14,000 In and Out-of-network
$9,350 In-network
Drugs Covered:No

Ready to sign up for Devoted LIBERTY CHOICE Georgia (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans. 

Devoted LIBERTY CHOICE Georgia (PPO) qualifies for a monthly Medicare Give Back Benefit of $160.00.

Premium Reduction:$160.00

Premium Breakdown

Devoted LIBERTY CHOICE Georgia (PPO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.
Part B Part C Part B Give Back Total
$185.00 $0.00 $160.00 $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.

Additional Benefits

Devoted LIBERTY CHOICE Georgia (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Endodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Periodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Restorative Services
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Fluoride Treatment
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Oral Exams
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Other Diagnostic Dental Services
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Other Preventive Dental Services
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)

Diagnostic procedures/lab services/imaging

  • Diagnostic tests and procedures
    • Out-of-Network: $0-95 copay (Authorization Required)
  • Lab services
    • Out-of-Network: $0-40 copay or 20% coinsurance (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: $0-75 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: $0-300 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0-95 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $0-75 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $0-300 copay (Authorization Required)
  • Lab services
    • In-Network: $0-40 copay (Authorization Required)

Doctor visits

  • Primary
    • Out-of-Network: $15 copay per visit
  • Specialist
    • In-Network: $50 copay per visit
    • Out-of-Network: $15-50 copay per visit
  • Primary
    • In-Network: $0 copay

Emergency care/Urgent care

  • Urgent care
    • $0-45 copay per visit (always covered)
  • Emergency
    • $110 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • Out-of-Network: $50 copay
  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • In-Network: $50 copay

Ground ambulance

    • In-Network: $0-350 copay
    • Out-of-Network: $0-350 copay or 20% coinsurance

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • In-Network: $0 copay
  • Hearing aids
    • In-Network: $599-899 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • In-Network: $50 copay
    • Out-of-Network: $50 copay
  • Fitting/evaluation
    • Out-of-Network: $0 copay
  • Hearing aids
    • Out-of-Network: $599-899 copay (Limits Apply)
  • Hearing aids OTC
    • Not covered

Inpatient hospital coverage

    • In-Network: $325 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
    • Out-of-Network: $325 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $14,000 In and Out-of-network
      $9,350 In-network

Medical equipment/supplies

  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: 20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: $0 copay (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 20-40% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • Out-of-Network: 30% coinsurance (Authorization Required)
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: 30% coinsurance (Authorization Required)
    • In-Network: 0-20% coinsurance (Authorization Required)

Mental health services

  • Outpatient individual therapy visit
    • In-Network: $45 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $45 copay (Authorization Required)
    • Out-of-Network: $45 copay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: $45 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • Out-of-Network: $325 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: $45 copay (Authorization Required)
  • Outpatient individual therapy visit
    • Out-of-Network: $45 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • In-Network: $325 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $45 copay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $45 copay (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: $0-425 copay per visit (Authorization Required)
    • In-Network: $0-425 copay per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: $0 copay

Rehabilitation services

  • Occupational therapy visit
    • Out-of-Network: $35 copay
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: $50 copay
  • Occupational therapy visit
    • In-Network: $35 copay
  • Physical therapy and speech and language therapy visit
    • In-Network: $50 copay

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 60
      $0 per day for days 61 through 100 (Authorization Required)
    • Out-of-Network: 35% per stay (Authorization Required)

Transportation

    • Not covered

Vision

  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Not covered
  • Routine eye exam
    • Out-of-Network: $0 copay (Limits Apply)
  • Upgrades
    • In-Network: $0 copay (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Upgrades
    • Out-of-Network: $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for Devoted LIBERTY CHOICE Georgia (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Table of Contents

Get Help Enrolling

Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

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All plan-related information on this site is from CMS.gov and Medicare.gov. We only use data released publicly each year. While our goal is always to provide fact-based, accurate information, information is subject to change, and some data may be inaccurate. Contact a plan for a Summary of Benefits.

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