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DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) in 2026, please refer to our full plan details page.
DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) is a PPO C-SNP 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 C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP).
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 C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $37.60. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 $615.00 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 $7800.00 (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 $7800.00 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 C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) plan features an annual drug deductible of $615. For Tier 1 preferred generics, standard pharmacy and standard mail-order costs are an $18 copay for a 1-month supply, $36 for a 2-month supply, and $54 for a 3-month supply. Tier 2 generic drugs require a $19 copay for a 1-month supply, $38 for a 2-month supply, and $57 for a 3-month supply through these same standard channels. For higher-tier medications, standard pharmacy and mail-order services require a 21% coinsurance for Tier 3 preferred brands, 33% coinsurance for Tier 4 non-preferred drugs, and 25% coinsurance for a 1-month supply of Tier 5 specialty drugs. In contrast, Tier 6 select care drugs are highly affordable, offering coverage with no copay for 1-month, 2-month, or 3-month supplies.
Additional Benefits
The DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) plan offers comprehensive coverage with predictable costs, including no copay and no coinsurance for primary care visits, preventive services, and home health care. Specialist visits, mental health sessions, and routine hearing exams require a low $15 copay with no coinsurance. Additionally, dental benefits feature no copay or coinsurance up to a $2,000 annual limit, while eyewear is covered with no copay up to a $300 annual maximum. For more intensive medical needs, inpatient hospital stays require a $475 daily copay for the first few days and no copay thereafter, while emergency room visits carry a $130 copay. Outpatient surgeries, lab services, and home infusions are available with no copay, though other specialized treatments like dialysis and durable medical equipment require coinsurance. Skilled nursing facility care is also highly accessible, offering no copay for the first 20 days of your stay.
Inpatient Hospital See details
Inpatient hospital benefits for DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) require no coinsurance, with acute stays costing a $475 daily copay for days 1 through 5 (no copay for days 6 and beyond) and psychiatric stays costing $475 daily for days 1 through 4 (no copay for days 5 through 90). This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) with no coinsurance, featuring no copays for ambulatory surgical center and blood services. Outpatient hospital services require copays ranging from $0 to $575, observation services have a $475 copay per stay, and outpatient substance abuse sessions have a $15 copay.
Partial Hospitalization See details
Partial hospitalization is covered under the DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) plan with a $105.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) covers ground ambulance services with a copay of no copay to $315 and coinsurance, and air ambulance services with a 20% coinsurance and a copay, with prior authorization required for both. Transportation services to plan-approved or health-related locations are not covered.
Emergency Services See details
Emergency services are covered by DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no copay to a $45 copay with no coinsurance, and worldwide emergency services are covered up to $25,000 with a $130 copay (no coinsurance) for care and a $315 copay with 20% coinsurance for transportation.
Primary Care See details
Primary care benefits under DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) feature no copay and no coinsurance for primary care physician visits. Specialist, mental health, psychiatric, podiatry, and opioid treatment services require a $15 copay and no coinsurance, while physical and occupational therapies have a $15 to $50 copay and no coinsurance. Chiropractic services are not covered, but telehealth is available with no copay to a $45 copay and no coinsurance.
Preventive Services See details
DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) offers preventive services with no copay and no coinsurance, which includes annual physical exams, kidney disease education, and diabetes self-management training. Additional preventive services are partially covered, providing coverage for fitness, weight management, and nutritional therapy, while services like in-home safety assessments, personal emergency response systems, therapeutic massage, and in-home support are not covered.
Hearing Services See details
Hearing services are partially covered by DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP), offering routine exams with no deductible for a $15 copay and no coinsurance, and up to two prescription hearing aids per year for a $399 to $699 copay and no coinsurance. OTC hearing aids, along with inner ear, outer ear, and over-the-ear prescription hearing aids, are not covered.
Vision Services See details
Vision services are partially covered by DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) with no deductibles, as other eye exam services are not covered. Routine eye exams are covered once per year with a $0 to $15 copay and no coinsurance, while eyewear is covered with no copay or coinsurance up to a $300 annual combined maximum for contacts, eyeglasses, frames, and upgrades.
Dental Services See details
Dental Services are partially covered by DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) up to a $2,000 annual maximum, featuring no copay and no coinsurance for preventive and most comprehensive services, and a $15 copay and no coinsurance for Medicare-covered dental. Implants, orthodontics, maxillofacial prosthetics, other diagnostic services, and other preventive services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) with no copay and no coinsurance, subject to prior authorization. Medicare Part B chemotherapy, radiation, and other Part B drugs have no copay and range from no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and range from no coinsurance to 20% coinsurance.
Dialysis Services See details
DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) partially covers medical equipment with no copays, though prior authorization is required. Covered benefits include durable medical equipment with 20% to 50% coinsurance, prosthetics and medical supplies with no coinsurance to 20% coinsurance, and diabetic supplies with no coinsurance to 50% coinsurance, while diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP), with prior authorization required. Lab services feature no copay and no coinsurance, diagnostic tests have a copay of $0 to $95 with no coinsurance, and outpatient X-rays have no copay but require coinsurance. Diagnostic radiological services start at no copay with no coinsurance, while therapeutic radiological services require a minimum 20% coinsurance and a copay.
Home Health Services See details
Home Health Services are covered under the DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) plan with no copay and no coinsurance, although prior authorization is required for these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services under the DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) plan require prior authorization and feature no coinsurance, but only some services are covered. Standard cardiac, intensive cardiac, pulmonary, and SET for PAD services are not covered, though they are associated with a $15 copay.
Skilled Nursing Facility (SNF) See details
DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but allowing admission without a prior 3-day inpatient hospital stay. You will pay no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, with no coverage provided for additional days beyond the standard Medicare limit.
Other Services See details
Other services are partially covered by DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP), featuring no copay and no coinsurance for over-the-counter items up to $50 every three months, diabetic shoes, and additional preventive services. Acupuncture and meal benefits are not covered.
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