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Jefferson Health Plans Flex (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Flex (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Jefferson Health Plans Flex (PPO) in 2026, please refer to our full plan details page.
Jefferson Health Plans Flex (PPO) is a PPO plan offered by Thomas Jefferson University available for enrollment in 2025 to people living in Southeastern PA, Central PA and Eastern PA. The overall rating for this plan is not yet available for 2026.
It's important to know that Jefferson Health Plans Flex (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 Jefferson Health Plans Flex (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 Jefferson Health Plans Flex (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.
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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $10000.00 (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 $10000.00 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:
Sign up for Jefferson Health Plans Flex (PPO)
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Drug Coverage
The Jefferson Health Plans Flex (PPO) plan features a $0 drug deductible, meaning your prescription coverage begins immediately. Under this plan, you will pay no copay for Tier 1 preferred generic drugs filled at standard pharmacies or through standard mail order. For Tier 2 generic drugs, copays start at $5 for a one-month supply and go up to $15 for a three-month supply. Brand name and specialty medications are subject to coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 25% coinsurance, while Tier 4 non-preferred drugs carry a 32% coinsurance. Specialty drugs in Tier 5 are covered with a 33% coinsurance for a one-month supply.
Additional Benefits
The Jefferson Health Plans Flex (PPO) offers robust coverage with no copay and no coinsurance for primary care visits, preventive services, and home health care. Specialist visits require a $25 copay with no coinsurance, while inpatient hospital stays feature no coinsurance and no copay for days 7 through 90. Outpatient hospital services, urgent care, and emergency room visits are also covered with fixed copays and no coinsurance, ensuring predictable costs for emergency and routine medical needs. For supplemental care, this plan provides dental benefits up to a $3,500 annual limit with no copay or coinsurance for most preventive and comprehensive services. Routine vision and hearing exams are available for a $25 copay with no coinsurance, alongside allowances for eyewear and prescription hearing aids. Additionally, members can access over-the-counter items with no copay and no coinsurance up to $160 every three months, alongside affordable acupuncture coverage.
Inpatient Hospital See details
Jefferson Health Plans Flex (PPO) partially covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring copayments for the initial days of a stay and no copay for days 7 through 90. However, additional days, upgrades, and non-Medicare-covered stays are not covered by this plan.
Outpatient Services See details
Jefferson Health Plans Flex (PPO) covers outpatient services with no coinsurance, including outpatient hospital and observation services for a $300 copay, and ambulatory surgical center services for a $200 copay. Outpatient substance abuse services require a $35 copay per individual or group session, while outpatient blood services are covered with no copay or coinsurance.
Partial Hospitalization See details
Jefferson Health Plans Flex (PPO) covers partial hospitalization services with a $70.00 copay and no coinsurance. Prior authorization is required for some of these covered services.
Ambulance and Transportation Services See details
Jefferson Health Plans Flex (PPO) covers ambulance services with a $250 copay and no coinsurance for ground transport, and a 20% coinsurance with no copay for air transport, with prior authorization required. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency services are covered by Jefferson Health Plans Flex (PPO) with a $100 copay and no coinsurance, and urgently needed services are covered with a $20 copay and no coinsurance, with both copays waived if admitted to the hospital within 24 hours. Worldwide emergency and urgent services are partially covered with no copay or coinsurance up to a $50,000 maximum, though worldwide emergency transportation is not covered.
Primary Care See details
Jefferson Health Plans Flex (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $25 copay and no coinsurance. Other covered benefits, such as physical therapy, psychiatric care, and podiatry, have copays ranging from $20 to $35 with no coinsurance, though chiropractic care is only partially covered because other chiropractic services are not covered.
Preventive Services See details
Jefferson Health Plans Flex (PPO) covers preventive services, including annual physical exams, kidney disease education, and select screenings, with no copay and no coinsurance. This benefit is partially covered, as services like telemonitoring and memory fitness are included, while sub-services such as health education, weight management, and nutrition therapy are not covered.
Hearing Services See details
Jefferson Health Plans Flex (PPO) hearing services are partially covered, featuring routine hearing exams once per year with a $25 copay and no coinsurance, while fitting evaluations and OTC hearing aids are not covered. Prescription hearing aids are covered once every two years with no coinsurance and a copay ranging from $500 to $1,975, though inner ear, outer ear, and over the ear models are not covered.
Vision Services See details
Jefferson Health Plans Flex (PPO) offers partially covered vision services, which include one routine eye exam per year for a $25 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance, allowing for unlimited contact lenses and one pair of eyeglasses per year up to a $200 maximum, but individual eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Jefferson Health Plans Flex (PPO) offers partially covered dental services up to a maximum annual benefit of $3,500 for both in-network and out-of-network care. Covered Medicare dental services require a $25 copay and no coinsurance, while other covered preventive and comprehensive dental services have no copay and no coinsurance. Fluoride treatment, adjunctive general services, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Jefferson Health Plans Flex (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy and other Part B drugs feature no copay and a coinsurance ranging from no coinsurance up to 20%, while Part B insulin drugs require a $35 copay and a coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Jefferson Health Plans Flex (PPO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment benefits under the Jefferson Health Plans Flex (PPO) are covered with no copays, though prior authorization is required. Durable medical equipment, prosthetics, medical supplies, and diabetic shoes carry a 20% coinsurance, while diabetic supplies range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Jefferson Health Plans Flex (PPO) partially covers diagnostic services with no copay or coinsurance for diagnostic procedures, though lab services are not covered. Covered radiological services require prior authorization and include a $30 copay for outpatient X-rays, a minimum $250 copay for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Jefferson Health Plans Flex (PPO) covers Home Health Services with no copay and no coinsurance, although prior authorization is required for these services.
Cardiac Rehabilitation Services See details
Jefferson Health Plans Flex (PPO) provides cardiac rehabilitation benefits where some services are covered with no copay and no coinsurance. However, standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Jefferson Health Plans Flex (PPO) with no coinsurance, featuring no copay for days 1 through 20 and a $175 daily copay for days 21 through 100. Prior authorization is required, a three-day prior hospital stay is not required, and additional days beyond the standard 100 Medicare-covered days are not covered.
Other Services See details
Jefferson Health Plans Flex (PPO) partially covers other services, offering acupuncture for a $10 copay and no coinsurance up to 20 treatments per year, and over-the-counter items with no copay and no coinsurance up to $160 every three months. Meal benefits, Naloxone, and other miscellaneous services are not covered.
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