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Jefferson Health Plans Flex Plus (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Flex Plus (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 Plus (PPO) in 2025, please refer to our full plan details page.
Jefferson Health Plans Flex Plus (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 Plus (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 Plus (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 Plus (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $37.00. 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 Plus (PPO)
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Drug Coverage
The Jefferson Health Plans Flex Plus (PPO) plan has an enhanced alternative drug benefit with a $0 deductible. During the initial coverage phase, you'll pay varying costs depending on the drug tier and pharmacy. For example, standard generic drugs have a $5 copay at standard pharmacies and 25% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you will pay nothing for Medicare Part D 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 Plus (PPO) plan offers a wide range of benefits, including coverage for inpatient and outpatient services, with varying copays. The plan also covers primary care, preventive services, hearing, vision, and dental services, with specific copays and coverage limits for each. Additionally, the plan includes coverage for ambulance services, emergency services, and home health services, with specific cost-sharing requirements. This plan provides coverage for a variety of other services, such as home infusion, dialysis, medical equipment, diagnostic and radiological services, and skilled nursing facility stays, each with its own cost-sharing structure. The plan also covers acupuncture and over-the-counter items, with limitations on the number of treatments and maximum benefit amounts. However, some services like Cardiac Rehabilitation Services, and certain vision and dental services, are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including both Acute and Psychiatric, are covered. For days 1-60, the copay is $800, and the copay for a Medicare-covered stay is $400.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services and observation services with a $250 copay, and ambulatory surgical center services with a $150 copay. Individual and group sessions for outpatient substance abuse have a copay between $20 and $20. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial hospitalization is covered under the Jefferson Health Plans Flex Plus (PPO) plan, with a $70 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Jefferson Health Plans Flex Plus (PPO) plan. Ground ambulance services have a $250 copay, while air ambulance services have 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 Plus (PPO) plan. Emergency Services have a $100 copay, and Urgently Needed Services have a $10 copay; there is no coinsurance for either. Worldwide Emergency Services has a maximum plan benefit coverage of $50,000. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Jefferson Health Plans Flex Plus (PPO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, podiatry services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $15 copay, routine chiropractic care has a $20 copay for up to 6 visits per year, physician specialist services have a $20 copay, and mental health specialty services, podiatry services, psychiatric services, and opioid treatment program services have a $20 copay.
Preventive Services See details
The Jefferson Health Plans Flex Plus (PPO) plan covers preventive services, including Medicare-covered services with prior authorization, annual physical exams, and additional preventive services, with no copay or coinsurance. The plan does not cover Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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 Benefit, 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 (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services.
Hearing Services See details
Hearing Services include routine hearing exams with a $20 copay for one visit per year, and prescription hearing aids with a maximum plan benefit of $1000 every two years. Fitting/Evaluation for Hearing Aid, Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, Prescription Hearing Aids - Over the Ear, and OTC Hearing Aids are not covered.
Vision Services See details
Vision services are covered, including routine eye exams with no copay and are available once per year, and eyewear. Eyewear includes contact lenses with no copay and eyeglasses (lenses and frames) with a $200 maximum plan benefit coverage amount per year, while eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services include Medicare dental services with a $20 copay, oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, endodontics, periodontics, prosthodontics, removable, maxillofacial prosthetics, and oral and maxillofacial surgery. Orthodontic services are covered up to a $2,000 annual maximum, and fluoride treatment, adjunctive general services, implant services, and orthodontics are not covered.
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 other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis Services are covered by the Jefferson Health Plans Flex Plus (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, while Prosthetic Devices and Medical Supplies have a 20% coinsurance. Diabetic Supplies have between 0% and 20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have no copay, while Lab Services are not covered. Diagnostic Radiological Services have a copay of $250, Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a copay of $35.
Home Health Services See details
Home Health Services are covered by the Jefferson Health Plans Flex Plus (PPO) plan with no copay or coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Jefferson Health Plans Flex Plus (PPO) plan, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Jefferson Health Plans Flex Plus (PPO) plan. For days 1-20, there is no copay, and for days 21-100, the copay is $203.
Other Services See details
Other Services includes coverage for acupuncture and over-the-counter (OTC) items. Acupuncture has a limit of 20 treatments per year. OTC items have a maximum benefit of $125.00 every three months, and this plan offers nicotine replacement therapy (NRT) as a Part C OTC benefit. Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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