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DEVOTED CHOICE GIVEBACK 002 UT (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED CHOICE GIVEBACK 002 UT (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED CHOICE GIVEBACK 002 UT (PPO) in 2026, please refer to our full plan details page.
DEVOTED CHOICE GIVEBACK 002 UT (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2026 to people living in Utah. The overall rating for this plan is not yet available for 2026.
It's important to know that DEVOTED CHOICE GIVEBACK 002 UT (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about DEVOTED CHOICE GIVEBACK 002 UT (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For DEVOTED CHOICE GIVEBACK 002 UT (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $184.70. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $605.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $13900.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $13900.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The DEVOTED CHOICE GIVEBACK 002 UT (PPO) plan features an annual prescription drug deductible of $605. For Tier 1 preferred generic drugs, members pay no copay for one-month, two-month, or three-month supplies at standard pharmacies and standard mail order. Tier 2 generic drugs are also highly affordable, requiring a $3 copay for a one-month supply at standard retail and mail order locations. For brand-name and specialty medications, costs are structured as coinsurance rather than flat copays. Tier 3 preferred brand drugs carry a 21% coinsurance for all supply lengths, while Tier 4 non-preferred drugs require a 25% coinsurance. Tier 5 specialty drugs are also subject to a 25% coinsurance and are limited to a one-month supply.
Additional Benefits
The DEVOTED CHOICE GIVEBACK 002 UT (PPO) plan provides affordable medical coverage, featuring no copay and no coinsurance for primary care doctor visits, preventive services, and home health care. Specialist doctor visits require a $55 copay, and inpatient hospital stays have a $475 daily copay for the first four days, followed by no copay for days five through 90. Emergency room visits carry a $115 copay, which is waived upon admission, while urgent care services range from no copay to a $40 copay. For extra benefits, the plan features no copay for preventive dental services up to $250 annually and no copay for prescription eyewear up to a $200 yearly limit. Routine vision exams range from no copay to a $20 copay, while hearing exams require a $55 copay, and prescription hearing aids carry a $599 to $899 copay. Eligible members also receive a $93 allowance every three months for over-the-counter health items with no copay.
Inpatient Hospital See details
DEVOTED CHOICE GIVEBACK 002 UT (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $475 daily copay for days 1 through 4 and no copay for days 5 through 90 per stay. Non-Medicare-covered stays, acute hospital upgrades, and additional psychiatric inpatient days are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED CHOICE GIVEBACK 002 UT (PPO) with no coinsurance, featuring a $0 to $575 copay for outpatient hospital services and a $475 copay per stay for observation services. Ambulatory surgical center and blood services are available with no copay, while individual and group outpatient substance abuse sessions require a $50 copay.
Partial Hospitalization See details
The DEVOTED CHOICE GIVEBACK 002 UT (PPO) plan covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
DEVOTED CHOICE GIVEBACK 002 UT (PPO) covers ambulance services with prior authorization, offering ground transport with a copay ranging from no copay to $315 and no coinsurance, and air transport with a 20% coinsurance and no copay. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency services are covered by DEVOTED CHOICE GIVEBACK 002 UT (PPO) with a $115 copay and no coinsurance, with the copay waived if admitted to the hospital within 24 hours. Urgently needed services feature no copay to a $40 copay and no coinsurance, while worldwide emergency services are covered up to $25,000 with a $115 copay for emergency or urgent care and a $315 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
DEVOTED CHOICE GIVEBACK 002 UT (PPO) offers primary care physician services with no copay and no coinsurance, and specialist visits for a $55 copay and no coinsurance. Other covered benefits, including physical therapy, occupational therapy, psychiatric, and mental health services, carry copays ranging from $35 to $55 with no coinsurance, though podiatry is not covered, and some chiropractic services are covered but routine and other chiropractic services are not.
Preventive Services See details
Preventive Services are partially covered by DEVOTED CHOICE GIVEBACK 002 UT (PPO) with no copay and no coinsurance for covered options such as annual physical exams, fitness benefits, and kidney disease education. Non-covered sub-services include in-home safety assessments, personal emergency response systems, medical nutrition therapy, therapeutic massages, and home-based palliative care.
Hearing Services See details
DEVOTED CHOICE GIVEBACK 002 UT (PPO) covers hearing services, including one routine exam per year for a $55 copay and no coinsurance, as well as unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a $599.00 to $899.00 copay for up to two devices per year, though OTC hearing aids and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED CHOICE GIVEBACK 002 UT (PPO), which excludes other eye exam services but covers one routine eye exam per year with a $0 to $20 copay, no coinsurance, and no deductible. Eyewear is also covered with no copay, no coinsurance, and no deductible up to a combined maximum of $200 annually for contacts, frames, lenses, and upgrades.
Dental Services See details
DEVOTED CHOICE GIVEBACK 002 UT (PPO) offers partially covered dental services, featuring a $55 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for other covered preventive and comprehensive services up to a $250 annual maximum. Orthodontics, implant services, and maxillofacial prosthetics are not covered under this plan.
Home Infusion bundled Services See details
DEVOTED CHOICE GIVEBACK 002 UT (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance, while chemotherapy, radiation, and other Part B drugs have no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by DEVOTED CHOICE GIVEBACK 002 UT (PPO) with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
DEVOTED CHOICE GIVEBACK 002 UT (PPO) covers medical equipment with no copays, including durable medical equipment at a 15% coinsurance and prosthetics and medical supplies ranging from no coinsurance to 20% coinsurance. Diabetic equipment is partially covered with diabetic supplies ranging from no coinsurance to 15% coinsurance, but diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
DEVOTED CHOICE GIVEBACK 002 UT (PPO) covers diagnostic and radiological services with prior authorization, offering no coinsurance alongside no copay for lab services and a $0 to $95 copay for diagnostic procedures. Radiological services feature no copay for outpatient X-rays, a $0 minimum copay for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology services.
Home Health Services See details
DEVOTED CHOICE GIVEBACK 002 UT (PPO) covers Home Health Services with no copay and no coinsurance. Prior authorization is required before receiving these services.
Cardiac Rehabilitation Services See details
DEVOTED CHOICE GIVEBACK 002 UT (PPO) covers Cardiac Rehabilitation Services with no copay and no coinsurance, subject to prior authorization. While some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by DEVOTED CHOICE GIVEBACK 002 UT (PPO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, but a three-day prior hospital stay is not required for admission.
Other Services See details
DEVOTED CHOICE GIVEBACK 002 UT (PPO) partially covers other services, offering over-the-counter (OTC) items and additional preventive services with no copay and no coinsurance. Under this benefit, acupuncture and meal benefits are not covered, but eligible members receive up to $93 every three months for OTC items.
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