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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 2026, 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 2026.
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 $32.70. 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 offers a $0 drug deductible, allowing your prescription coverage to begin immediately without any upfront out-of-pocket costs. Under this plan, there is no copay for Tier 1 preferred generic and Tier 2 generic drugs when filled for up to a three-month supply at standard pharmacies or through standard mail order. This ensures that essential everyday medications remain highly accessible and affordable. For brand-name and specialty medications, cost-sharing is structured as coinsurance. Members pay a 25% coinsurance for Tier 3 preferred brand drugs and a 32% coinsurance for Tier 4 non-preferred drugs across all available supply durations. Tier 5 specialty drugs carry a 33% coinsurance for a one-month supply through both standard pharmacies and standard mail order.
Additional Benefits
The Jefferson Health Plans Flex Plus (PPO) offers comprehensive coverage with no copay or coinsurance for primary care doctor visits, preventive services, home health care, and routine annual eye and hearing exams. For specialized care, members pay a $20 copay with no coinsurance for specialist visits and most dental services, while inpatient hospital stays require copayments between $435 and $800. Emergency care is available with a $100 copay, and urgent care visits require a $10 copay, with no coinsurance for either service. This plan also features valuable supplemental benefits, including up to $5,000 in covered dental services and a $165 quarterly over-the-counter allowance with no copays. Routine vision benefits cover one pair of eyeglasses up to a $200 limit annually, and skilled nursing facility stays require no copay for the first 20 days. Most durable medical equipment and dialysis services require no copay and a 20% coinsurance, while Medicare Part B drugs require up to a 20% coinsurance.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Jefferson Health Plans Flex Plus (PPO) with no coinsurance, requiring prior authorization and copayments ranging from $435 to $800 per stay. Additional days, upgrades, and non-Medicare-covered stays are not covered under this plan.
Outpatient Services See details
Outpatient services covered by the Jefferson Health Plans Flex Plus (PPO) include outpatient hospital and observation services for a $250 copay with no coinsurance, and ambulatory surgical center services for a $150 copay with no coinsurance. Outpatient substance abuse services require a $20 copay and no coinsurance per individual or group session, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Partial hospitalization is covered by Jefferson Health Plans Flex Plus (PPO) with a $70.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Jefferson Health Plans Flex Plus (PPO) covers ground ambulance services with a $250 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Transportation services are partially covered with no copay and no coinsurance for up to 50 one-way trips per year to plan-approved locations, while transportation to any health-related location is not covered.
Emergency Services See details
Jefferson Health Plans Flex Plus (PPO) covers emergency services with a $100 copay and urgently needed services with a $10 copay, with no coinsurance for either service and copays waived if admitted to the hospital within 24 hours. Worldwide emergency and urgent care are partially covered with no copay or coinsurance up to a $50,000 maximum benefit limit, though worldwide emergency transportation is not covered.
Primary Care See details
Primary care benefits under Jefferson Health Plans Flex Plus (PPO) feature no copay and no coinsurance for primary care physician visits, while specialist visits, therapies, and mental health services require a $20 copay and no coinsurance. Chiropractic services are partially covered, offering routine care for a $20 copay but excluding other chiropractic services, all with no coinsurance.
Preventive Services See details
Jefferson Health Plans Flex Plus (PPO) covers preventive services, including annual physicals, kidney disease education, memory fitness, and telemonitoring, with no copay and no coinsurance. This benefit is partially covered, as sub-services such as health education, personal emergency response systems, in-home safety assessments, medical nutrition therapy, and weight management programs are not covered.
Hearing Services See details
Hearing services are partially covered by Jefferson Health Plans Flex Plus (PPO), excluding fitting/evaluations, OTC hearing aids, and inner, outer, or over-the-ear prescription hearing aids. Routine hearing exams are covered once per year with no copay and no coinsurance, while covered prescription hearing aids are limited to one every two years with no coinsurance and a copay ranging from $500 to $1,975.
Vision Services See details
Jefferson Health Plans Flex Plus (PPO) offers partially covered vision services with no copay, no coinsurance, and no deductible for covered care. This benefit includes one routine eye exam and one pair of eyeglasses (up to a $200 limit) annually, as well as unlimited contact lenses; however, other eye exam services, individual eyeglass lenses, individual eyeglass frames, and upgrades are not covered.
Dental Services See details
Jefferson Health Plans Flex Plus (PPO) covers Medicare dental services for a $20 copay and no coinsurance, and other dental services with no copay and no coinsurance up to a $5,000 annual maximum. Dental services are partially covered under this plan, as fluoride treatments, adjunctive general services, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Jefferson Health Plans Flex Plus (PPO) covers Home Infusion bundled Services with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs require no coinsurance to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by Jefferson Health Plans Flex Plus (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
Jefferson Health Plans Flex Plus (PPO) covers medical equipment with no copays, featuring a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic shoes. Diabetic supplies are also covered with no copay and a coinsurance ranging from no coinsurance to 20%, subject to prior authorization and manufacturer limitations.
Diagnostic and Radiological Services See details
Jefferson Health Plans Flex Plus (PPO) partially covers diagnostic services and covers radiological services, with prior authorization required for both. Diagnostic procedures have no copay and no coinsurance, but lab services are not covered. Radiological services require a $35 copay and coinsurance for X-rays, a minimum $250 copay for diagnostic radiology, and a minimum 20% coinsurance along with a copay for therapeutic radiology.
Home Health Services See details
Home health services are covered under the Jefferson Health Plans Flex Plus (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Jefferson Health Plans Flex Plus (PPO) does not cover Cardiac Rehabilitation Services, as all sub-services, including standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation, are excluded.
Skilled Nursing Facility (SNF) See details
Jefferson Health Plans Flex Plus (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, a $160 daily copay for days 21 through 100, and additional days beyond the standard 100-day Medicare benefit period are not covered.
Other Services See details
Other Services under the Jefferson Health Plans Flex Plus (PPO) are partially covered, offering acupuncture limited to 20 treatments per year and over-the-counter items up to $165 every three months with no copay and no coinsurance. Meal benefits and Naloxone coverage are not covered under this plan.
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