Medicare Plan Lookup Official CMS data · Contract Year 2027
CMS 2027 data

2027 Medicare plan code

H5453-002

Medicare Plan

DEVOTED CHOICE GIVEBACK 002 GA (PPO) · Devoted Health · Local PPO · Greater Atlanta

Full CMS plan ID: H5453-002-000

H5453-002-000 is the full CMS identifier for the H5453-002 Medicare plan. Common searches include H5453 002 and H5453002.

2027

Spaces or dashes work: H5216-435-002 · S2135 802

● CMS 2027 plan record

DEVOTED CHOICE GIVEBACK 002 GA (PPO)

H5453-002-000 Greater Atlanta Local PPO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Days 1–6 $400 / day
Days 7–90 $0 / day
Total of listed copays · 6 charged days $2,400
Out-of-network

Tier 1: $400 / day for days 1–6; $0 / day for days 7–90; $0 per stay

Point of service

Not separately reported

02

Emergency transport

Ambulance

Ground · in-network$0–$350 copay
Air · in-network20% coinsurance
03

Emergency services

Emergency room

$115 copay

Waived if admitted within 24 hours

04

Medical maximum

Maximum out-of-pocket

In-network$9,850
Combined in + out$14,400
05

Skilled care at home

Home health

In-network$0 cost share
Out-of-network40% coinsurance
06

Monthly cost

Premium & giveback

Part C premium$0 / month
Consolidated C + D$0 / month

CMS reports a Part B premium reduction of $184.7 per month.

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-networkPrimary Care Physician Services: $0 cost share
Out-of-network7a: $15 copay

Specialist

In-networkPhysician Specialist Services: $45 copay
Out-of-network7d: $55 copay

Preventive care

In-networkAnnual Physical Exam: $0 cost share; Kidney Disease Education Services: $0 cost share; Glaucoma Screening: $0 cost share; Diabetes Self-Management Training: $0 cost share; Digital Rectal Exams: $0 cost share; EKG following Welcome Visit: $0 cost share
Out-of-network14b: $0 cost share; 14d: $0 cost share; 14e1: $0 cost share; 14e2: $0 cost share; 14e4: $0 cost share; 14e5: $0 cost share; 14a: $0 cost share
Diagnostics & imaging4 benefits

Diagnostic procedures & tests

In-networkDiagnostic Procedures/Tests: $0–$95 copay
Out-of-network8a1: $0–$105 copay

Laboratory services

In-networkLab Services: 20% coinsurance + $0–$45 copay
Out-of-network8a2: $10–$55 copay + 20% coinsurance

X-rays & standard imaging

In-networkOutpatient X-Ray Services: $0–$75 copay
Out-of-network8b3: $0–$85 copay

MRI, CT & PET imaging

In-networkDiagnostic Radiological Services: $25–$300 copay
Out-of-network8b1: $35–$350 copay
Urgent & hospital care6 benefits

Urgent care

In-networkUrgently Needed Services: $0–$40 copay
Out-of-networkNot separately reported

Emergency room

In-network$115 copay
Out-of-networkNot separately reported

Ground ambulance

In-network$0–$350 copay
Out-of-network$0–$350 copay

Air ambulance

In-network20% coinsurance
Out-of-network20% coinsurance

Outpatient hospital

In-networkOutpatient Hospital Services: $0–$500 copay; Observation Services: $400 copay
Out-of-network9a1: 0%–40% coinsurance; 9a2: $400 copay

Outpatient surgery / ASC

In-networkAmbulatory Surgical Center (ASC) Services: $0–$400 copay
Out-of-network9b: $0–$500 copay
Recovery & therapy5 benefits

Home health

In-network$0 cost share
Out-of-network40% coinsurance

Skilled nursing facility

In-networkSkilled nursing facility: Tier 1: $0 / day for days 1–20; $221 / day for days 21–100
Out-of-networkSkilled nursing facility: Tier 1: 40% coinsurance

Cardiac & pulmonary rehabilitation

In-networkCardiac Rehabilitation Services: $30 copay; Intensive Cardiac Rehabilitation Services: $30 copay; Pulmonary Rehabilitation Services: $25 copay; SET for PAD Services: $20 copay; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable
Out-of-network3-1: $40 copay; 3-2: $40 copay; 3-3: $35 copay; 3-4: $30 copay

Occupational therapy

In-networkOccupational Therapy Services: $35 copay
Out-of-network7c: $45 copay

Physical & speech therapy

In-networkPhysical Therapy and Speech-Language Pathology Services: $45–$50 copay
Out-of-network7i: $55 copay
Behavioral health2 benefits

Mental health services

In-networkPartial Hospitalization Program: $70 copay; Individual Sessions for Mental Health Specialty Services: $45 copay; Group Sessions for Mental Health Specialty Services: $45 copay; Individual Sessions for Psychiatric Services: $45 copay; Group Sessions for Psychiatric Services: $45 copay; Inpatient psychiatric hospital: Tier 1: $400 / day for days 1–5; $0 / day for days 6–90
Out-of-network5a: $70 copay; 7e1: $55 copay; 7e2: $55 copay; 7h1: $55 copay; 7h2: $55 copay; Inpatient psychiatric hospital: Tier 1: $400 / day for days 1–6; $0 / day for days 7–90; $0 per stay

Substance use treatment

In-networkIntensive Outpatient Program Services: $70 copay; Individual Sessions for Outpatient Substance Abuse: $45 copay; Group Sessions for Outpatient Substance Abuse: $45 copay
Out-of-network5b: $70 copay; 9c1: $55 copay; 9c2: $55 copay
Specialty care2 benefits

Podiatry

In-networkPodiatry Services: $45 copay; 7f(NMC): Not applicable
Out-of-network7f: $55 copay

Chiropractic

In-networkChiropractic Services: $15 copay
Out-of-network7b: $25 copay
Supplemental benefits7 benefits

Dental

In-networkMedicare Dental Services: $45 copay; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Restorative Services: $0 cost share; Endodontics: $0 cost share; Periodontics: $0 cost share; Prosthodontics, removable: $0 cost share; Implant Services: $0 cost share; Prosthodontics, fixed: $0 cost share; Oral and Maxillofacial Surgery: $0 cost share; Adjunctive General Services: $0 cost share
Out-of-network16a: $55 copay; 16b1: $0 cost share; 16b2: $0 cost share; 16b4: $0 cost share; 16b5: $0 cost share; 16c1: $0 cost share; 16c2: $0 cost share; 16c3: $0 cost share; 16c4: $0 cost share; 16c6: $0 cost share; 16c7: $0 cost share; 16c8: $0 cost share; 16c10: $0 cost share

Vision

In-networkEye Exams: $0–$45 copay; Other Eye Exam Services: Not applicable; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: $0 cost share
Out-of-network17a: $0–$55 copay; 17a1: $0 cost share; 17b: $0 cost share; 17b1: $0 cost share; 17b2: $0 cost share; 17b3: $0 cost share; 17b4: $0 cost share; 17b5: $0 cost share

Hearing

In-networkHearing Exams: $45 copay; Prescription Hearing Aids (all types): $599–$899 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Out-of-network18a: $55 copay; 18a1: $35 copay; 18a2: $35 copay; 18b1: 90% coinsurance

Transportation

Not applicable
In-network10b(NMC): Not applicable
Out-of-networkNot separately reported

Fitness & wellness

In-networkFitness Benefit: $0 cost share
Out-of-network14c4: 0%–90% coinsurance

Over-the-counter allowance

Not applicable
In-networkOver-the-Counter (OTC) Items: Not applicable
Out-of-networkNot separately reported

Meals

Not applicable
In-networkMeal Benefit: Not applicable
Out-of-networkNot separately reported
Plan costs & rulesCoverage overview

Premium & Part B giveback

$0 Part C premium / month · CMS reports a Part B premium reduction of $184.7 per month.

Maximum out-of-pocket (MOOP)

In-network$9,850
Combined in + out$14,400

Medical deductibles

In-networkNot reported
Out-of-networkNot reported

Annual health deductible

$200

Combined network deductible

Not separately reported

Part D premium

$0 / month

Network & referrals

Local PPO · Referrals: Not required · Out-of-network coverage: Yes

Prescription drugs5 tiers

Part D deductible

$461 / year

Drug tier 1

Standard retail: $0 copay · Preferred retail: $0 copay · 30-day supply

Drug tier 2

Standard retail: $0 copay · Preferred retail: $0 copay · 30-day supply

Drug tier 3

Standard retail: 15% coinsurance · Preferred retail: 15% coinsurance · 30-day supply

Drug tier 4

Standard retail: 25% coinsurance · Preferred retail: 25% coinsurance · 30-day supply

Drug tier 5

Standard retail: 26% coinsurance · Preferred retail: 26% coinsurance · 30-day supply

Using this plan

Understand H5453-002-000

Plain-language context built from this plan’s 2027 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.

Plan at a glance

A quick read on this plan

DEVOTED CHOICE GIVEBACK 002 GA (PPO) is a 2027 Local PPO offered by Devoted Health in Greater Atlanta. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals. Its listed inpatient copay stages total $2,400 across 6 charged days.

Common benefit costs

What you may pay

These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.

Routine care

Primary care physician
Primary Care Physician Services: $0 cost share
Specialist
Physician Specialist Services: $45 copay
Laboratory services
Lab Services: 20% coinsurance + $0–$45 copay

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
Diagnostic Procedures/Tests: $0–$95 copay
MRI, CT & PET imaging
Diagnostic Radiological Services: $25–$300 copay
Outpatient hospital
Outpatient Hospital Services: $0–$500 copay; Observation Services: $400 copay

The service setting and billing details can change what you pay.

Emergency & hospital care

Emergency room
$115 copay
Listed inpatient stages
$2,400 total

6 charged inpatient days are included in the calculated total. Actual costs depend on the care received and plan rules.

Helpful context

Terms worth knowing

Maximum out-of-pocket (MOOP)

This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.

Part B premium reduction (“giveback”)

A giveback may reduce the amount you pay toward Medicare Part B; it is not usually paid to you as cash. The CMS record notes: CMS reports a Part B premium reduction of $184.7 per month.

Availability

Who can enroll

Service area
Greater Atlanta (GA)
Plan type
Local PPO
Contract / plan
H5453-002
Coverage year
2027

Enrollment generally requires Medicare eligibility and residence in the plan's service area. Confirm eligibility and the exact service area with the plan before enrolling.

Supplemental coverage

Extra benefits reported

Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.

DentalMedicare Dental Services: $45 copay; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Restorative Services: $0 cost share; Endodontics: $0 cost share; Periodontics: $0 cost share; Prosthodontics, removable: $0 cost share; Implant Services: $0 cost share; Prosthodontics, fixed: $0 cost share; Oral and Maxillofacial Surgery: $0 cost share; Adjunctive General Services: $0 cost share
VisionEye Exams: $0–$45 copay; Other Eye Exam Services: Not applicable; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: $0 cost share
HearingHearing Exams: $45 copay; Prescription Hearing Aids (all types): $599–$899 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Fitness & wellnessFitness Benefit: $0 cost share

Plan-specific answers

Frequently asked questions

Where is H5453-002-000 available?

DEVOTED CHOICE GIVEBACK 002 GA (PPO) is listed for Greater Atlanta (GA). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H5453-002-000?

The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $9,850. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H5453-002-000?

The listed consolidated Part C and Part D premium is $0 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H5453-002-000?

The plan record lists $115 copay, waived when an admission meets the plan's stated timing rule.

Does H5453-002-000 report extra benefits?

Yes. CMS reports dental, vision, hearing, fitness & wellness. See the detailed benefit rows and official plan documents for limits and conditions.

Source trail

Official CMS, Contract Year 2027

Plan identity and benefits come from CMS PBP data. Benefits and drug cost sharing come from the approved annual PBP tabular extract and its CMS dictionary. Premiums and drug deductibles are cross-checked with the annual Landscape. Geography comes from annual PlanArea and PlanRegionArea records, including exact segments and partial-county or employer/group qualifiers. Quick-reference values should be confirmed in current official plan documents.

PBP benefits ↗ Landscape data ↗ County service area ↗

Plan context

Where H5453-002-000 fits

Full CMS plan ID
H5453-002-000
Contract
H5453
Base plan code
H5453-002
Segment
000
Carrier
Devoted Health
Plan type
Local PPO
Service area
Greater Atlanta (GA)

County/service-area foundation

CMS service-area entries

Service areas come from the annual CMS PlanArea and PlanRegionArea tables for this exact contract, plan, and segment. Partial-county and employer/group qualifiers remain part of the coverage area. Regional PPO county entries use the matching annual Landscape expansion of the CMS region.

  • Bartow, GA
  • Cherokee, GA
  • Clayton, GA
  • Cobb, GA
  • Coweta, GA
  • DeKalb, GA
  • Douglas, GA
  • Fayette, GA
  • Forsyth, GA
  • Fulton, GA
  • Gwinnett, GA
  • Henry, GA

4 additional service-area entries are retained in the data record.

Exact county navigation

These links are limited to named counties tied to this exact medical plan segment. Partial-county entries remain labeled for verification.

Show 16 county links

Same CMS contract

H5453-001-000 DEVOTED CHOICE 001 GA (PPO) Greater Atlanta · Local PPO H5453-003-000 DEVOTED CHOICE MA ONLY 003 GA (PPO) Georgia · Local PPO H5453-004-000 DEVOTED CHOICE 004 GA (PPO) Greater Georgia · Local PPO H5453-005-000 DEVOTED CHOICE GIVEBACK 005 GA (PPO) Greater Georgia · Local PPO H5453-010-000 DEVOTED CHOICE 010 GA (PPO) Augusta and Savannah · Local PPO H5453-011-000 DEVOTED CHOICE GIVEBACK 011 GA (PPO) Augusta and Savannah · Local PPO H5453-015-000 DEVOTED C-SNP CHOICE ENHANCED 015 GA (PPO C-SNP) Greater Atlanta · Local PPO H5453-016-000 DEVOTED C-SNP CHOICE PLUS 016 GA (PPO C-SNP) Georgia · Local PPO

About this code

What H5453-002-000 identifies

H5453-002-000 is a Contract Year 2027 Medicare plan segment code. Searches written as H5453-002, H5453 002, or the compact full CMS ID H5453002000 refer to this plan or its base plan code.

Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.