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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 2025, 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 2025.
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 has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying costs depending on the drug tier and pharmacy type. For example, you'll pay a $5 copay for preferred generic drugs at a standard or mail-order pharmacy. After your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Jefferson Health Plans Flex (PPO) plan offers a range of benefits with varying cost-sharing structures. Inpatient hospital stays require a $250 copay for the first six days, with no copay for the remaining days. The plan covers a variety of outpatient services, with copays ranging from $15 to $375 depending on the service. The plan also includes coverage for emergency services, primary care, preventive services, hearing, vision, and dental services, with copays typically between $15 and $100. Additional benefits include home health services with no copay, home infusion services, and coverage for medical equipment with coinsurance. Prior authorization is required for several services, and some services have limitations or exclusions.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you pay a $250 copay for days 1-6, and no copay for days 7-90.
Outpatient Services See details
Outpatient services include coverage for all outpatient hospital services, observation services, ambulatory surgical center (ASC) services, and outpatient substance abuse services. Outpatient hospital and observation services have a $375 copay, ASC services have a $245 copay, and individual and group outpatient substance abuse sessions have a copay between $35 and $35. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Jefferson Health Plans Flex (PPO) plan, but requires prior authorization. You will have a $70 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Jefferson Health Plans Flex (PPO) plan. Ground ambulance services have a $255 copay, while air ambulance services have a 20% coinsurance; transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Jefferson Health Plans Flex (PPO) plan. Emergency Services have a $100 copay, while Urgently Needed Services have a $20 copay, and both have no coinsurance. Worldwide Emergency Services have a maximum plan benefit coverage of $50,000. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Jefferson Health Plans Flex (PPO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, and physician specialist services with a $35 copay. This plan also covers mental health specialty services, podiatry services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits with a $0 - $35 copay, and opioid treatment program services with a $35 copay.
Preventive Services See details
Preventive services are covered, including Medicare-covered zero dollar preventive services, annual physical exams, and additional preventive services. Health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, remote access technologies, home and bathroom safety devices and modifications, and counseling services are not covered. Fitness benefits, telemonitoring services, kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit are covered.
Hearing Services See details
Hearing exams are covered with a $35 copay, while routine hearing exams are limited to one per year. Prescription hearing aids are covered up to a maximum of $1000 every two years, but fitting/evaluation for hearing aids, inner ear hearing aids, outer ear hearing aids, over the ear hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision Services includes eye exams with a $35 copay, and also covers contact lenses and eyeglasses (lenses and frames). Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Jefferson Health Plans Flex (PPO) plan covers Medicare Dental Services with a $35 copay. Other dental services include oral exams (3 visits per year), dental x-rays (1 per year), other diagnostic dental services, prophylaxis (cleaning) (3 per year), restorative services, endodontics, periodontics, prosthodontics (removable), maxillofacial prosthetics, prosthodontics (fixed), and oral and maxillofacial surgery. Fluoride treatment, implant services, and orthodontics are not covered. Orthodontic Services has a maximum benefit of $1,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Jefferson Health Plans Flex (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment are covered under the Jefferson Health Plans Flex (PPO) plan. DME has a 20% coinsurance, and requires prior authorization. Prosthetic Devices and Medical Supplies both have a 20% coinsurance, while Diabetic Supplies have a 0-20% coinsurance depending on the service.
Diagnostic and Radiological Services See details
The Jefferson Health Plans Flex (PPO) plan covers Diagnostic and Radiological Services, but Lab Services are not covered. Diagnostic Procedures/Tests have no copay, while Diagnostic Radiological Services have a $250 copay and Therapeutic Radiological Services have 20% coinsurance. Outpatient X-Ray Services have a $35 copay.
Home Health Services See details
Home Health Services are covered by the Jefferson Health Plans Flex (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but not Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. There is a copay for Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, and Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Jefferson Health Plans Flex (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $203. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Jefferson Health Plans Flex (PPO) plan covers acupuncture with a $10 copay for up to 20 treatments per year, and over-the-counter (OTC) items with a maximum benefit of $150 every three months. Other services such as meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and more are not covered.
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