A non-government entity
Clover Health Choice (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Clover Health Choice (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Clover Health Choice (PPO) in 2026, please refer to our full plan details page.
Clover Health Choice (PPO) is a PPO plan offered by Clover Health Holdings, Inc. available for enrollment in 2025 to people living in Select NJ Counties. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Clover Health 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 Clover Health 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 Clover Health 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. Additionally, this plan comes with a Part B Premium reduction of $20.00. You must continue to pay paying your reduced 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 a $150.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $13900.00 (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 $13900.00 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 Clover Health Choice (PPO) prescription drug plan features an annual drug deductible of $150 before coverage begins. For Tier 1 preferred generics, there is no copay for up to a three-month supply at standard pharmacies and standard mail order. Tier 2 generic medications cost a low $5 copay for a one-month supply at standard pharmacies, with no copay required for a three-month supply ordered through standard mail. Brand-name and specialty medications require higher cost-sharing under this plan. Tier 3 preferred brands carry a standard pharmacy copay of $47 for a one-month supply, while Tier 4 non-preferred drugs cost a $100 copay. Specialty drugs in Tier 5 require a 31% coinsurance for both standard pharmacy and mail-order fills.
Additional Benefits
The Clover Health Choice (PPO) plan offers robust medical coverage featuring no copay and no coinsurance for primary care visits, while specialist visits require a low $10 copay. For hospital care, inpatient acute stays carry a daily copay of $399 for the first six days with no copay thereafter, while outpatient hospital services require a $350 copay. Emergency care is accessible with a $115 copay, which is waived if you are admitted within 24 hours. This plan also includes valuable supplemental benefits, such as preventive dental care with no copay and comprehensive dental coverage up to a $2,000 annual limit. Additionally, members benefit from routine vision and hearing exams for a $10 copay, a $300 yearly allowance for eyewear, and a $110 quarterly over-the-counter item reimbursement with no copay. Home health services and the first 20 days of skilled nursing facility stays are also fully covered with no copay or coinsurance.
Inpatient Hospital See details
Clover Health Choice (PPO) covers inpatient hospital services with no coinsurance, requiring prior authorization for both acute and psychiatric stays. Medicare-covered acute stays require a $399 daily copay for days 1 to 6 (no copay for days 7 and beyond), while psychiatric stays require a $339 daily copay for days 1 to 6 (no copay for days 7 to 90). This benefit is partially covered, as upgrades, psychiatric additional days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Clover Health Choice (PPO) covers outpatient hospital and observation services for a $350 copay, and ambulatory surgical center services for a $275 copay, both with no coinsurance. Outpatient substance abuse services require no coinsurance with copays of $40 for individual sessions and $30 for group sessions, while outpatient blood services are fully covered with no copay and no coinsurance.
Partial Hospitalization See details
Clover Health Choice (PPO) covers partial hospitalization services with an $80 copay and no coinsurance. Prior authorization may be required for these services.
Ambulance and Transportation Services See details
Clover Health Choice (PPO) covers ground and air ambulance services with a $350 copay and no coinsurance, although prior authorization is required. Transportation services to plan-approved or health-related locations are not covered under this plan.
Emergency Services See details
Clover Health Choice (PPO) covers emergency services with a $115 copay and urgently needed services with a $35 copay, both featuring no coinsurance and waived fees if admitted to the hospital within 24 hours. Worldwide emergency, urgent, and transportation services are also covered up to a $50,000 limit with no coinsurance and copays of $115, $40, and $350, respectively.
Primary Care See details
Clover Health Choice (PPO) provides primary care physician services with no copay and no coinsurance, and specialist visits with a $10 copay and no coinsurance. Other covered benefits, including physical therapy ($15 copay), psychiatric sessions ($30 to $40 copay), and telehealth ($0 to $10 copay), also require no coinsurance, while podiatry and routine chiropractic services are not covered.
Preventive Services See details
Clover Health Choice (PPO) preventive services are partially covered with no copay and no coinsurance for annual physical exams, kidney disease education, and select screenings. However, many additional services are not covered, including health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, smoking cessation, enhanced disease management, telemonitoring, home modifications, and counseling.
Hearing Services See details
Clover Health Choice (PPO) hearing services are partially covered, offering an annual routine exam for a $10 copay and no coinsurance, alongside unlimited hearing aid evaluations. Up to two prescription hearing aids are covered yearly with a copay between $499 and $999 and no coinsurance, though OTC devices and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
Vision services are covered by Clover Health Choice (PPO), offering one routine eye exam per year with a $10 copay and no coinsurance, while other eye exams are not covered. Eyewear is partially covered with no copay, no coinsurance, and a $300 annual limit for one pair of contacts or eyeglasses, though individual lenses, frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by Clover Health Choice (PPO) up to a $2,000 annual maximum, excluding orthodontic services which are not covered. Medicare dental services have a $10 copay and no coinsurance, preventive services have no copay and no coinsurance, and other covered comprehensive services require either a $20 copay and no coinsurance or a 50% coinsurance and no copay.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Clover Health Choice (PPO) with no copay, although prior authorization is required. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Clover Health Choice (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Clover Health Choice (PPO) with no copays, though coinsurance requirements vary by item. Durable medical equipment and prosthetics carry a 20% coinsurance, while diabetic equipment features no coinsurance but is only partially covered, with diabetic supplies and therapeutic shoes or inserts not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Clover Health Choice (PPO) with prior authorization required. Diagnostic services feature no coinsurance, with no copay for lab work and a $0 to $200 copay for procedures, while radiological services require a $30 copay for X-rays, a minimum $50 copay for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Clover Health Choice (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered under Clover Health Choice (PPO) with no coinsurance and require prior authorization, but some services are covered while standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered. These non-covered services carry copayments ranging from $20 to $25.
Skilled Nursing Facility (SNF) See details
Clover Health Choice (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 $218 daily copay for days 21 through 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Clover Health Choice (PPO) partially covers other services, providing over-the-counter (OTC) items with no copay and no coinsurance up to a $110 limit every three months through reimbursement. Acupuncture, meal benefits, and nicotine replacement therapy are not covered.
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