DEVOTED CHOICE GIVEBACK 002 NE (PPO) Medicare Advantage Plan H9802-002 • 2027 • Buffalo County, NE
- Monthly Premium
- $0.00Plus Part B premium.
- Medical Deductible
- $50
- Maximum Out-of-Pocket
- $9850.00In-network
- Part B Giveback
- −$159.80 reduction
- Prescription Coverage
- Enhanced, $461.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- Buffalo County, NE
- Local Enrollment
- 29 beneficiaries in Buffalo County
DEVOTED CHOICE GIVEBACK 002 NE (PPO) Introduction
DEVOTED CHOICE GIVEBACK 002 NE is a Medicare Advantage PPO plan offered by Devoted Health. It uses a Preferred Provider Organization (PPO) provider network and comes with prescription drug coverage. For the 2027 plan year it has a $0.00 monthly premium, $50 medical deductible, and $9850.00 in-network maximum out-of-pocket. CMS Plan ID H9802-002 identifies this plan. The 2027 Part D prescription drug deductible is $461.00.
You must live in Buffalo County, Nebraska to enroll in this plan. CMS reports 29 beneficiaries enrolled in this plan in Buffalo County. For assistance with this plan, new members can call (844)978-2770 (TTY 711).
Compare Similar Plans in Buffalo County
Compare this plan with the two most-enrolled PPO plans available in Buffalo County, Nebraska. Enrollment is based on CMS local enrollment data.
| Plan Detail | DEVOTED CHOICE GIVEBACK 002 NE | Blue Cross and Blue Shield of Nebraska MA Connect | DEVOTED CHOICE 001 NE |
|---|---|---|---|
| CMS Plan ID | H9802-002-0 |
H8181-002-0 |
H9802-001-0 |
| Local Enrollment | 29 | 272 | 64 |
| Monthly Premium | $0.00 | $0.00 | $0.00 |
| Medical Deductible | $50 | $0.00 | $0.00 |
| Maximum Out-of-Pocket | $9,850.00 | $6,650.00 | $4,800.00 |
| Part B Giveback | −$159.80 reduction | Not offered | Not offered |
| Primary Care | $0 copay | $0 copay | $0 copay |
| Specialist | $55 copay | $50 copay | $5-$40 copay |
| Part D Deductible | $461.00 | $400.00 | $650.00 |
| CMS Star Rating | Not yet rated | Not yet rated | Not yet rated |
| Dental | $0 copay | $0 copay | $0 copay |
| Vision | $0 copay | $0 copay | $0 copay |
| Hearing | $0 copay | $0 copay | $0 copay |
Plan Benefits
DEVOTED CHOICE GIVEBACK 002 NE has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The tables below detail the most common in-network out-of-pocket expenses for plan H9802-002.
You can also compare 2027 costs and coverage with last year, side-by-side: Plan H9802-002-0 Cost Compare.
Office Visits
- Primary care
- In-network: $0 copay
Out-of-network: $5 copay - Specialist
- In-network: $55 copay
Out-of-network: $55 copay
Preventive and Wellness Services
- Annual wellness exam
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Telehealth benefit
- In-network: $0-$55 copay
- Routine chiropractic
- Not covered
- Fitness benefits
- Coming soon
- Health education
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Counseling services
- Not covered
- Over-the-counter drug benefits
- Not covered
- Health transportation (non-emergency)
- Coming soon
Diagnostic, Lab, and Imaging Services
- Diagnostic radiology services
- In-network: $25-$300 copay
Out-of-network: $25-$300 copay - Lab services
- In-network: $0-$55 copay, 20% coinsurance
Out-of-network: $0-$55 copay, 20% coinsurance - Outpatient x-rays
- In-network: $0-$75 copay
Out-of-network: $0-$75 copay - Diagnostic tests and procedures
- In-network: $0-$95 copay
Out-of-network: $0-$95 copay
Emergency and Urgent Care Services
- Emergency room care
- $115 copay
- Worldwide emergency care
- Coming soon
- Urgent care
- $0-$40 copay
- Inpatient hospital care
- In-network:
Tier 1
$475 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Out-of-network:
$475 per day for days 1-5
$0 per day for days 6-90
$0 per stay - Skilled Nursing Facility
- In-network:
Tier 1
$0 per day for days 1-20
$218 per day for days 21-100
Out-of-network:
35% per stay - Ground ambulance
- In-network: $0-$325 copay
Out-of-network: $0-$325 copay
Mental Health Services
- Outpatient individual therapy
- In-network: $50 copay
Out-of-network: $55 copay - Outpatient group therapy
- In-network: $50 copay
Out-of-network: $55 copay - Inpatient psychiatric hospital care
- In-network:
Tier 1
$475 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Out-of-network:
$475 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Rehabilitation Services
- Physical therapy and speech and language therapy
- In-network: $55 copay
Out-of-network: $55 copay - Occupational therapy
- In-network: $35 copay
Out-of-network: $35 copay
Medical Equipment and Supplies
- Diabetes supplies
- In-network: $0 copay
Out-of-network: 50% coinsurance - Durable medical equipment
- In-network: 15% coinsurance
Out-of-network: 45% coinsurance - Prosthetics
- In-network: 0%-15% coinsurance
Out-of-network: 0%-35% coinsurance
Medicare Part B Drugs
- Chemotherapy
- In-network: 0%-20% coinsurance
Out-of-network: 40% coinsurance - Other Part B drugs (Medicare-covered)
- In-network: 0%-20% coinsurance
Out-of-network: 0%-40% coinsurance
Dental Services
- Oral exam
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Dental x-rays
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Cleaning
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Periodontics
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Endodontics
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Restorative services
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Implant services
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Orthodontics
- Not covered
- Oral/Maxillofacial surgery
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Vision Services
- Routine eye exam
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Contact lenses
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Eyeglass frames only
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Eyeglass lenses only
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Eyeglasses (frames & lenses)
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Upgrades
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Hearing Services
- Hearing exam
- In-network: $0 copay
Out-of-network: $35 copay - Fitting/evaluation
- In-network: $0 copay
Out-of-network: $35 copay - Prescription hearing aids
- In-network: $599-$899 copay
Out-of-network: 90% coinsurance - OTC hearing aids
- Not covered
Additional and Special Needs Services
- Adult day health services
- Not covered
- Home-based palliative care
- Not covered
- Personal emergency response system
- Coming soon
- Weight management programs
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Wigs for chemotherapy-related hair loss
- Coming soon
- Alternative therapies
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Massage therapy
- Not covered
- Home/bathroom safety devices
- In-network: $0 copay
Out-of-network: 45% coinsurance
Certain preventive services are covered 100% by DEVOTED CHOICE GIVEBACK 002 NE as a Part B benefit.
Prescription Drug Coverage
DEVOTED CHOICE GIVEBACK 002 NE includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.
This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | ($33.80) |
| Supplemental Part D Premium: | $$33.80 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | $24.60 |
| Low-Income Premium Subsidy Paid by CMS: | $0.00 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $461.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Devoted Health starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, DEVOTED CHOICE GIVEBACK 002 NE may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | Coming soon |
| Generic | $0.00 copay | Coming soon |
| Preferred Brand | 15% coinsurance | Coming soon |
| Non-Preferred Drug | 25% coinsurance | Coming soon |
| Specialty Tier | 26% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H9802)
Medicare Advantage (Part C) and Part D plans are rated each year by CMS on a 5-star scale. Ratings summarize plan performance across clinical care and member experience measures.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | Plan too new to be measured |
| Managing Chronic (Long Term) Conditions | Plan too new to be measured |
| Member Experience with Health Plan | Plan too new to be measured |
| Complaints and Changes in Plans Performance | Plan too new to be measured |
| Health Plan Customer Service | Plan too new to be measured |
| Drug Plan Customer Service | Plan too new to be measured |
| Complaints and Changes in the Drug Plan | Plan too new to be measured |
| Member Experience with the Drug Plan | Plan too new to be measured |
| Drug Safety and Accuracy of Drug Pricing | Plan too new to be measured |
Contact Information for Devoted Health
- Website
- Devoted Health Plan Page
- Providers
- Devoted Health Providers Page
- Formulary
- Devoted Health Formulary Page
- Pharmacy
- Devoted Health Pharmacy Page
- New Member Health Plan Help
- (844)978-2770
- New Member Health Plan TTY
- 711
- New Member Part D Help
- (844)978-2770
- New Member Part D TTY Users
- 711
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Devoted Health (official source) | http://www.devoted.com | October 4, 2026 |
| Medicare.gov | Understanding Medicare Advantage Plans | 25 May, 2025 |
| NCOA.org | 5 Steps to Choosing the Right Medicare Plan for You | 25 May, 2025 |
| Medicare.gov | Explore your Medicare coverage options | 25 May, 2025 |
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