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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 2025, 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 2025.
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:
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Drug Coverage
The Jefferson Health Plans Choice (PPO) plan has an "Enhanced Alternative" drug benefit. There is no deductible for prescription drugs. In the initial coverage phase, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. For example, a standard pharmacy will charge a $5 copay for preferred generic drugs, while preferred brand drugs have a 35% coinsurance. After your total drug costs reach $2000, you enter the next coverage phase.
Additional Benefits
The Jefferson Health Plans Choice (PPO) plan offers a variety of benefits with varying costs. Inpatient hospital stays have a $300 copay for the first five days, with no copay for the rest of the stay, while outpatient services have copays ranging from $25 to $325 depending on the service. The plan also covers primary care, preventive services, hearing, vision, and dental services. Primary care visits have varying copays, and vision services include coverage for routine eye exams, contact lenses, and eyeglasses with a $200 maximum benefit. Dental services include a $40 copay for Medicare-covered services, and other dental services. Additionally, the plan covers ambulance services, emergency services, and offers an OTC benefit.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization. For Inpatient Hospital-Acute, you pay a $300 copay for days 1-5, and a $0 copay for days 6-90; for Inpatient Hospital Psychiatric, you pay a $300 copay for days 1-5, and a $0 copay for days 6-90. Additional days, non-Medicare-covered stays, and upgrades for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $325 copay, Observation Services with a $325 copay, Ambulatory Surgical Center (ASC) Services with a $250 copay, and Outpatient Substance Abuse Services with a $25 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 Choice (PPO) plan, but requires prior authorization. You will have a $55 copay for this benefit.
Ambulance and Transportation Services See details
The Jefferson Health Plans Choice (PPO) plan covers ambulance services, with a $250 copay for ground ambulance services and a 20% coinsurance for air ambulance services. 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 by the Jefferson Health Plans Choice (PPO) plan. Emergency Services have a $100 copay, while Urgently Needed Services have a $10 copay, and neither service has coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Jefferson Health Plans Choice (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, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services. Physician Specialist Services have a $15 copay, Physical Therapy and Speech-Language Pathology Services have a $25 copay, and Additional Telehealth Benefits have a copay between $0 and $20. The plan requires prior authorization for Chiropractic Services, Occupational Therapy Services, Mental Health Specialty Services, Psychiatric Services, and Physical Therapy and Speech-Language Pathology Services.
Preventive Services See details
The Jefferson Health Plans Choice (PPO) plan covers preventive services, including Medicare-covered services with prior authorization, annual physical exams, and additional preventive services. Additional services such as Health Education, In-Home Safety Assessment, Personal Emergency Response System, and others are not covered.
Hearing Services See details
The Jefferson Health Plans Choice (PPO) plan covers hearing exams with a $30 copay for routine exams, and prescription hearing aids with a plan maximum of $1,000 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 Choice (PPO) plan covers routine eye exams once per year, and contact lenses with no limit. Eyeglasses (lenses and frames) are covered once per year with a maximum benefit of $200, while eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include Medicare dental services with a $40 copay, and other dental services including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, and oral and maxillofacial surgery. Fluoride treatment, implant services, adjunctive general services, and orthodontics are not covered. Orthodontic services have a maximum plan benefit of $3,500 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Jefferson Health Plans Choice (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance with no copay, but DME for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance with no copay, while Diabetic Supplies have a 0-20% coinsurance with no copay, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance with no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Jefferson Health Plans Choice (PPO) plan. Diagnostic Procedures/Tests have no copay, while Lab Services are not covered. Diagnostic Radiological Services have a copay of $200, and Therapeutic Radiological Services have a 20% coinsurance. Outpatient X-Ray Services have a $30 copay.
Home Health Services See details
Home Health Services are covered by the Jefferson Health Plans Choice (PPO) plan with no copay and no 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 technically covered, but Jefferson Health Plans Choice (PPO) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. This means that while this benefit is listed, you will have to pay the full cost for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Jefferson Health Plans Choice (PPO), but require prior authorization. You will have no copay for days 1-20, and a $203 copay per day for days 21-100.
Other Services See details
The Jefferson Health Plans Choice (PPO) plan covers acupuncture with a $10 copay per visit, up to 20 treatments per year, and also provides over-the-counter (OTC) items as a supplemental benefit, with a maximum coverage amount of $100 every three months. Other services such as meal benefits, and various additional services are not covered.
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