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DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) in 2026, please refer to our full plan details page.
DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) is a PPO D-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 DUAL CHOICE FULL 004 UT (PPO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
DEVOTED DUAL CHOICE FULL 004 UT (PPO D-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 DUAL CHOICE FULL 004 UT (PPO D-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 DUAL CHOICE FULL 004 UT (PPO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $34.40. 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 has a $990.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
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 $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 DUAL CHOICE FULL 004 UT (PPO D-SNP) plan has an annual prescription drug deductible of $615. For Tiers 1 through 4, which include preferred generic, generic, preferred brand, and non-preferred drugs, you will pay a 25% coinsurance at standard pharmacies and standard mail-order services. Additionally, standard pharmacies and standard mail-order services charge a 25% coinsurance for a 1-month supply of Tier 5 specialty drugs. For Tier 6 select care drugs, this plan offers no copay for 1-month, 2-month, and 3-month supplies filled at standard pharmacies or through standard mail order. This Medicare PPO D-SNP drug coverage helps beneficiaries understand their out-of-pocket prescription costs and plan their healthcare budget effectively.
Additional Benefits
The DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) plan offers comprehensive coverage for core medical needs, often with no copays for outpatient and primary care services. Inpatient hospital stays require a copay of $2,230 for acute care and $2,080 for psychiatric care per stay, both with no coinsurance. For outpatient procedures, specialist visits, and diagnostic services, you will generally face no copay, though varying coinsurance rates and prior authorizations may apply. This plan also includes valuable supplemental benefits, such as dental coverage up to $3,000 annually and a $400 yearly allowance for eyewear with no copays. Routine hearing exams and hearing aids are covered with no copay or low copays, while emergency room visits incur a $115 copay that is waived if you are admitted. Additionally, skilled nursing facility stays feature no copay for the first 20 days, followed by a $218 daily copay up to day 100.
Inpatient Hospital See details
DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) covers inpatient hospital services with no coinsurance, requiring a $2,230 copay per stay for acute care and a $2,080 copay per stay for psychiatric care. Prior authorization is required, and while unlimited additional days are covered for acute care, psychiatric additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) covers outpatient services with no copays, though coinsurance and prior authorization requirements apply. Outpatient hospital and ambulatory surgical center services have 0% to 50% coinsurance, while outpatient substance abuse and blood services require 30% coinsurance.
Partial Hospitalization See details
DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) covers partial hospitalization services with no copay and a 30% coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are offered by DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP), featuring no copay and a coinsurance of 0% to 50% for ground ambulance and 50% for air ambulance services. Although some transportation services are covered, trips to plan-approved or any health-related locations are not covered.
Emergency Services See details
Emergency services are covered by DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) with a $115 copay and no coinsurance, and the copay is waived if you are admitted to the hospital within 24 hours. Urgently needed services require no copay and a 0% to 30% coinsurance (up to $40 per visit), while worldwide emergency, urgent, and transportation services are covered with no copay and no coinsurance up to a $25,000 maximum.
Primary Care See details
DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) covers primary care physician services with no copay and no coinsurance, and telehealth services with no copay and 0% to 30% coinsurance. Specialist visits, mental health services, and physical, occupational, and speech therapies are covered with no copay and 30% coinsurance with prior authorization required, while podiatry and chiropractic services are not covered.
Preventive Services See details
Preventive services are covered by DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management training. This benefit is partially covered, as sub-services such as in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy, and therapeutic massages are not covered.
Hearing Services See details
DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) partially covers hearing services, offering routine hearing exams with no copay and 50% coinsurance, and prescription hearing aids with a copay between $0 and $299 and no coinsurance. OTC hearing aids, as well as 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 DUAL CHOICE FULL 004 UT (PPO D-SNP) with no deductibles, offering one annual routine eye exam with no copay and 0% to 50% coinsurance, though other eye exam services are not covered. Eyewear is also covered with no copay and no coinsurance, providing a combined maximum benefit of $400 per year for contacts, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) up to a $3,000 annual limit for both in- and out-of-network care. Medicare-covered dental services require no copay and 30% coinsurance, while other covered dental services have no copay and no coinsurance; however, other diagnostic services, other preventive services, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) with no copay, though prior authorization is required. Covered Part B chemotherapy and other Part B drugs require no copay and 0% to 20% coinsurance, while Part B insulin has a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) plan with no copay and a 20% coinsurance, and prior authorization is required.
Medical Equipment See details
DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay and coinsurance ranging from no coinsurance to 20%. Prior authorization is required, and certain equipment and supplies must be sourced from preferred vendors or manufacturers.
Diagnostic and Radiological Services See details
DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) covers diagnostic and radiological services with no copay, though prior authorization is required. Under this plan, diagnostic procedures and tests have no coinsurance, while lab services have a 50% coinsurance, therapeutic radiological services have a 20% coinsurance, and both diagnostic radiological and outpatient X-ray services have a 30% coinsurance.
Home Health Services See details
Home Health Services are covered under the DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) plan with no copay and no coinsurance. Prior authorization is required to receive these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) with no copay and require prior authorization. However, in practice some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require a 30% coinsurance.
Skilled Nursing Facility (SNF) See details
DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by DEVOTED DUAL CHOICE FULL 004 UT (PPO D-SNP), which offers over-the-counter (OTC) items up to $50 every three months and additional preventive services with no copay and no coinsurance. Acupuncture, meal benefits, and highly integrated dual eligible services are not covered.
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