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Jefferson Health Plans Flex Pro (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Flex Pro (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 Pro (PPO) in 2026, please refer to our full plan details page.
Jefferson Health Plans Flex Pro (PPO) is a PPO plan offered by Thomas Jefferson University available for enrollment in 2025 to people living in Southern PA, Eastern PA. The overall rating for this plan is not yet available for 2026.
It's important to know that Jefferson Health Plans Flex Pro (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 Pro (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 Pro (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $18.00. 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 $9000.00 (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 $9000.00 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:
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Drug Coverage
The Jefferson Health Plans Flex Pro (PPO) plan features a $0 drug deductible, allowing your prescription drug coverage to begin immediately. You will pay no copay for Tier 1 (Preferred Generic) and Tier 2 (Generic) medications filled at standard pharmacies or through standard mail order. This coverage applies to one-month, two-month, and three-month supplies of these generic drugs. For brand-name and specialty medications, your cost-sharing is based on coinsurance rather than copays. You will pay a 25% coinsurance for Tier 3 (Preferred Brand) drugs and a 34% coinsurance for Tier 4 (Non-Preferred) drugs. Tier 5 (Specialty) drugs require a 33% coinsurance for a one-month supply at standard pharmacies or through standard mail order.
Additional Benefits
Jefferson Health Plans Flex Pro (PPO) offers comprehensive medical coverage featuring no copay and no coinsurance for primary care visits, specialist appointments, preventive care, and home health services. Inpatient hospital stays require no coinsurance and a copay of either $375 per stay or $800 for days 1 through 60. Emergency services are covered with a $100 copay, which is waived if you are admitted to the hospital within 24 hours. Supplemental benefits include dental care covered up to a $5,000 annual limit with no copay for most covered services and a $15 copay for Medicare-covered dental care. Routine vision and hearing exams are available for a $15 copay, with additional allowances provided for eyewear and prescription hearing aids. Members also benefit from acupuncture sessions for a $10 copay and over-the-counter items with no copay up to a $150 limit every three months.
Inpatient Hospital See details
Jefferson Health Plans Flex Pro (PPO) partially covers inpatient acute and psychiatric hospital stays with no coinsurance and copayments of $375 per stay or $800 for days 1 through 60, with prior authorization required. Additional hospital days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Jefferson Health Plans Flex Pro (PPO) covers outpatient services with no coinsurance, including a $200 copay for outpatient hospital and observation services and a $125 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $20 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Jefferson Health Plans Flex Pro (PPO) with a $70 copay and no coinsurance. Prior authorization is required for some of these covered services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Jefferson Health Plans Flex Pro (PPO), which features a $225 copay and no coinsurance for ground ambulance services, and a 20% coinsurance with no copay for air ambulance services. Prior authorization is required for ambulance services, and transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Jefferson Health Plans Flex Pro (PPO) covers emergency services with a $100 copay and no coinsurance, and urgently needed services with a $15 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 and no coinsurance up to a $50,000 limit, though worldwide emergency transportation is not covered.
Primary Care See details
Jefferson Health Plans Flex Pro (PPO) covers primary care and specialist physician services with no copay and no coinsurance. Other services, such as physical therapy, mental health, and podiatry, require copays ranging from $15 to $20 with no coinsurance, though chiropractic benefits are only partially covered as other chiropractic services are excluded.
Preventive Services See details
Jefferson Health Plans Flex Pro (PPO) covers preventive services, including annual physical exams, kidney disease education, and diabetes self-management training, with no copay and no coinsurance. Additional preventive benefits are partially covered with no copay and no coinsurance, including telemonitoring and memory fitness, while sub-services such as health education, weight management, and counseling are not covered.
Hearing Services See details
Jefferson Health Plans Flex Pro (PPO) partially covers hearing services, offering one routine hearing exam per year for a $15 copay and no coinsurance, and one prescription hearing aid every two years with a copay ranging from $500 to $1,975 and no coinsurance. Fitting and evaluation services, OTC hearing aids, and inner-ear, outer-ear, or over-the-ear prescription aids are not covered.
Vision Services See details
Jefferson Health Plans Flex Pro (PPO) provides partially covered vision services with no deductibles, offering one routine eye exam per year for a $15 copay and no coinsurance, while other eye exams are not covered. Eyewear is also covered with no copay and no coinsurance for contact lenses and one pair of eyeglasses per year up to $300, but individual eyeglass lenses, frames, and upgrades are not covered.
Dental Services See details
Jefferson Health Plans Flex Pro (PPO) dental services are partially covered up to a $5,000 annual limit for both in-network and out-of-network care. Medicare-covered dental services require a $15 copay and no coinsurance, while other covered services have no copay and no coinsurance, though fluoride treatment, adjunctive general services, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Jefferson Health Plans Flex Pro (PPO) with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other Part B drugs require 0% to 20% coinsurance, while Part B insulin drugs carry a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by the Jefferson Health Plans Flex Pro (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Jefferson Health Plans Flex Pro (PPO) with no copays, though prior authorization is required. Members pay a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic shoes, while diabetic supplies range from no coinsurance up to 20% coinsurance.
Diagnostic and Radiological Services See details
Jefferson Health Plans Flex Pro (PPO) partially covers diagnostic services, providing diagnostic procedures and tests with no copay and no coinsurance, while lab services are not covered. Covered radiological services require prior authorization and include X-rays for a $35 copay plus coinsurance, diagnostic radiological services with a $170 minimum copay and no coinsurance, and therapeutic radiological services with a 20% minimum coinsurance and a copay.
Home Health Services See details
Home Health Services are covered by Jefferson Health Plans Flex Pro (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Jefferson Health Plans Flex Pro (PPO) does not cover Cardiac Rehabilitation Services, as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
Jefferson Health Plans Flex Pro (PPO) partially covers skilled nursing facility (SNF) services with no coinsurance, as additional days beyond the Medicare-covered limit are not covered. For covered days, there is no copay for days 1 through 20 and a $160 daily copay for days 21 through 100, with prior authorization required and no prior three-day hospital stay needed.
Other Services See details
Jefferson Health Plans Flex Pro (PPO) covers acupuncture with a $10.00 copay and no coinsurance for up to 20 treatments per year, and over-the-counter (OTC) items with no copay and no coinsurance up to a $150 limit every three months. Meal benefits and other additional services are not covered under this plan.
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