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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 2025, 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 2025.
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 $20.00. 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 has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay either a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, you may pay a $5 copay for preferred generic drugs at a standard pharmacy or 25% coinsurance for standard generic drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you will pay nothing for Medicare Part D covered drugs. This plan's premium may be reduced if you qualify for the low-income subsidy, where you will pay $20.00.
Additional Benefits
The Jefferson Health Plans Flex Pro (PPO) plan offers a variety of benefits with varying costs. You'll pay an $800 copay for inpatient hospital stays, and $250-$300 for outpatient services. You'll have a $15-$20 copay for primary care, mental health, and specialist visits. The plan also includes coverage for ambulance services, with a $225 copay for ground and 20% coinsurance for air. Additional benefits include routine hearing and vision exams with a $20 copay, and dental services with a $35 copay for oral exams. The plan also covers home health services, and skilled nursing facility services.
Inpatient Hospital See details
The Jefferson Health Plans Flex Pro (PPO) plan covers inpatient hospital stays, including acute and psychiatric care, with a copay of $800 per admission for days 1-60. Additional days and non-Medicare-covered stays for both acute and psychiatric care are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a $250 copay, and observation services, with a $300 copay. Ambulatory Surgical Center (ASC) services have a $150 copay, and outpatient substance abuse services are covered with a $20 copay for both individual and group sessions. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Jefferson Health Plans Flex Pro (PPO) plan, but requires prior authorization. You will have a $70 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Jefferson Health Plans Flex Pro (PPO) plan. Ground ambulance services have a $225 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 Pro (PPO) plan. Emergency Services have a $100 copay and no coinsurance, while Urgently Needed Services have a $15 copay and no coinsurance; 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 Pro (PPO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy with a $20 copay, physician specialist services with a $20 copay, and mental health specialty services with a $20 copay. The plan also covers podiatry services with a $20 copay, other health care professional services with a copay between $0 and $20, psychiatric services with a $20 copay, physical therapy and speech-language pathology services with a $20 copay, additional telehealth benefits with a copay between $0 and $20, and opioid treatment program services with a $20 copay. Routine chiropractic care has a $20 copay for up to 6 visits per year.
Preventive Services See details
The Jefferson Health Plans Flex Pro (PPO) plan covers preventive services, including Medicare-covered services with prior authorization, annual physical exams, and additional preventive services. Some services like health education, in-home safety assessments, and counseling services are not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $20 copay, and prescription hearing aids with a maximum benefit of $1000 every two years. Fitting/evaluation for hearing aids, prescription hearing aids (inner ear, outer ear, and over the ear), and OTC hearing aids are not covered.
Vision Services See details
The Jefferson Health Plans Flex Pro (PPO) plan covers vision services, including routine eye exams with a $20 copay. Eyewear is covered, with contact lenses and eyeglasses (lenses and frames) covered, and eyeglasses (lenses and frames) have a maximum benefit of $100 per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are covered, including oral exams with a $35 copay, 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. Fluoride treatment, implant services, adjunctive general services, and orthodontics are not covered. Orthodontic services have a maximum benefit of $2000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Jefferson Health Plans Flex Pro (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance, Prosthetics/Medical Supplies with a 20% coinsurance, and Diabetic Equipment, with Diabetic Supplies having a 0-20% coinsurance and Diabetic Therapeutic Shoes/Inserts with a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
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 $200, Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $35 copay.
Home Health Services See details
Home Health Services are covered by the Jefferson Health Plans Flex Pro (PPO) plan with no copay and no coinsurance, but prior authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Jefferson Health Plans Flex Pro (PPO) plan. Specifically, 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 are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Jefferson Health Plans Flex Pro (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 for SNF are not covered.
Other Services See details
Other Services includes acupuncture with a $10 copay, and over-the-counter items with a maximum benefit of $165 every three months. 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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