A non-government entity
Jefferson Health Plans Choice (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Choice (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 Choice (PPO) in 2026, please refer to our full plan details page.
Jefferson Health Plans Choice (PPO) is a PPO plan offered by Thomas Jefferson University available for enrollment in 2025 to people living in Southern New Jersey. The overall rating for this plan is not yet available for 2026.
It's important to know that Jefferson Health Plans Choice (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 Choice (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 Choice (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 Choice (PPO)
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Drug Coverage
The Jefferson Health Plans Choice (PPO) plan features a $0 drug deductible, meaning your prescription coverage begins immediately. Under this plan, you will pay no copay for Tier 1 preferred generic drugs through standard pharmacies or standard mail order. For Tier 2 generic drugs, costs are also low, with a copay of $5 for a one-month supply, $10 for a two-month supply, and $15 for a three-month supply. For higher-tier medications, the plan transitions to a coinsurance model for standard pharmacies and standard mail order. You will pay a 25% coinsurance for Tier 3 preferred brand drugs, a 32% coinsurance for Tier 4 non-preferred drugs, and a 33% coinsurance for a one-month supply of Tier 5 specialty drugs.
Additional Benefits
Jefferson Health Plans Choice (PPO) offers comprehensive coverage with no copay and no coinsurance for primary care visits, annual physicals, and home health services. Specialist visits require a low $15 copay, while inpatient hospital stays feature copays between $300 and $800 for the initial days and no copay for days 6 through 90. Outpatient hospital services carry a $325 copay, and emergency room visits are covered with a $100 copay, which is waived if you are admitted. This plan also features robust dental, vision, and hearing benefits, including preventive and comprehensive dental care with no copay up to a $3,500 annual limit. Routine vision exams and eyewear are covered with no copay or deductible up to $200 annually, while routine hearing exams require a $30 copay. Additionally, durable medical equipment and dialysis services are covered with a 20% coinsurance and no copay, and over-the-counter items are covered with no copay up to $100 every three months.
Inpatient Hospital See details
Jefferson Health Plans Choice (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring copays of $300 to $800 for the initial days of a stay and no copay for days 6 through 90. Prior authorization is required, and additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Jefferson Health Plans Choice (PPO) covers outpatient hospital and observation services for a $325 copay, and ambulatory surgical center services for a $250 copay, both with no coinsurance. Outpatient substance abuse services require a $25 copay per session with no coinsurance, while outpatient blood services have no copay, coinsurance, or deductible.
Partial Hospitalization See details
Partial hospitalization is covered by Jefferson Health Plans Choice (PPO) with a $55.00 copay and no coinsurance. Prior authorization is required for certain services under this benefit.
Ambulance and Transportation Services See details
Jefferson Health Plans Choice (PPO) covers ground ambulance services with a $250 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required. Transportation services to plan-approved or other health-related locations are not covered under this plan.
Emergency Services See details
Jefferson Health Plans Choice (PPO) covers emergency services with a $100 copay and no coinsurance, and urgently needed services with a $10 copay and no coinsurance, with both copays waived if you are 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 maximum benefit, though worldwide emergency transportation is not covered.
Primary Care See details
Jefferson Health Plans Choice (PPO) covers primary care physician services with no copay and no coinsurance, while specialist and routine podiatry visits require a $15 copay and no coinsurance. Mental health, psychiatric, and physical therapies carry a $25 copay and no coinsurance, and chiropractic care is partially covered as other chiropractic services are not covered.
Preventive Services See details
Jefferson Health Plans Choice (PPO) covers preventive services, such as annual physical exams and kidney disease education, with no copay and no coinsurance. However, additional preventive services are only partially covered, with excluded benefits including health education, weight management, medical nutrition therapy, and in-home safety assessments.
Hearing Services See details
Jefferson Health Plans Choice (PPO) provides partially covered hearing services, which include one routine annual hearing exam for a $30 copay and no coinsurance, plus one prescription hearing aid every two years with a copay of $500 to $1,975 and no coinsurance. Fitting and evaluation services, over-the-counter (OTC) hearing aids, and inner, outer, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Jefferson Health Plans Choice (PPO) provides partially covered vision services with no copay, no coinsurance, and no deductible for covered benefits. Covered services include one routine eye exam per year and unlimited contact lenses or one pair of eyeglasses up to a $200 annual limit, while other eye exam services, individual eyeglass lenses, individual eyeglass frames, and upgrades are not covered.
Dental Services See details
Jefferson Health Plans Choice (PPO) covers comprehensive and preventive dental services with no copay and no coinsurance up to a $3,500 annual maximum, while Medicare-covered dental services require a $40 copay and no coinsurance. This partially covered benefit excludes fluoride treatments, implants, orthodontics, and adjunctive general services, but includes cleanings, exams, and x-rays limited to three visits per year.
Home Infusion bundled Services See details
Home Infusion bundled services are covered by Jefferson Health Plans Choice (PPO) with no copay, though prior authorization and step therapy may apply. Under this benefit, Medicare Part B chemotherapy and other drugs require no coinsurance to 20% coinsurance, while Part B insulin is covered with a $35 copay, no coinsurance to 20% coinsurance, and no deductible.
Dialysis Services See details
Jefferson Health Plans Choice (PPO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Jefferson Health Plans Choice (PPO) covers durable medical equipment, prosthetics, and diabetic equipment with no copay, though prior authorization is required. You will 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 Choice (PPO) covers diagnostic procedures and tests with no copay and no coinsurance, though lab services are not covered. Radiological services require prior authorization and include outpatient X-rays for a $30 copay, diagnostic radiological services with a minimum $200 copay and no coinsurance, and therapeutic radiological services with a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Jefferson Health Plans Choice (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Jefferson Health Plans Choice (PPO) technically covers Cardiac Rehabilitation Services with no copay and no coinsurance; however, this benefit is not covered in practice because cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are all not covered.
Skilled Nursing Facility (SNF) See details
Jefferson Health Plans Choice (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $185 copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Jefferson Health Plans Choice (PPO), featuring acupuncture with a $10.00 copay and no coinsurance for up to 20 treatments per year, and over-the-counter items with no copay and no coinsurance up to a $100.00 limit every three months. Meal benefits are not covered under this plan.
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