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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 2025, 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 4 out of 5 stars in 2025.
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 $14000.00 (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 $14000.00 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 Clover Health Choice (PPO)
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Drug Coverage
The Clover Health Choice (PPO) plan has a $150 deductible for prescription drugs. After the deductible is met, you'll pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, in the initial coverage phase, you'll pay a $5 copay for preferred generic drugs at a standard pharmacy, and a $47 copay for standard generic drugs at a standard pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Clover Health Choice (PPO) plan offers coverage for a variety of healthcare services. Inpatient hospital stays have a copay, with the amount varying based on the type of care. Outpatient services and emergency services also have copays, while primary care and specialist visits range from no copay to a $40 copay, depending on the service. The plan includes additional benefits such as hearing and vision services with copays for exams and coverage for eyewear and hearing aids. Dental services are covered with a $2,000 annual maximum. Dialysis services and medical equipment have coinsurance, while home health services have no copay.
Inpatient Hospital See details
The Clover Health Choice (PPO) plan covers inpatient hospital services, including acute and psychiatric care. For inpatient hospital-acute, you will pay a $399 copay for days 1-6, and no copay for days 7-90. For inpatient hospital psychiatric, you will pay a $339 copay for days 1-6, and no copay for days 7-90.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $375 copay, Observation Services with a $375 copay, Ambulatory Surgical Center (ASC) Services with a $275 copay, Outpatient Substance Abuse Services with a $40 copay for individual sessions and a $30 copay for group sessions, and Outpatient Blood Services. Prior authorization is required for some services.
Partial Hospitalization See details
Partial Hospitalization is covered under the Clover Health Choice (PPO) plan, but requires prior authorization. You will have an $80 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Clover Health Choice (PPO) plan. Ground and Air Ambulance Services have a $350 copay, with no coinsurance, and 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 Clover Health Choice (PPO) plan. Emergency Services has a $110 copay, and Urgently Needed Services has a $35 copay, while Worldwide Emergency Coverage has a $110 copay, Worldwide Urgent Coverage has a $40 copay, and Worldwide Emergency Transportation has a $350 copay.
Primary Care See details
The Clover Health Choice (PPO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $15 copay, physician specialist services have a $10 copay, occupational therapy and physical therapy have a $15 copay, and telehealth services have a copay between $0 and $10. Individual and group sessions for mental health and psychiatric services have a copay, with individual sessions costing $40 and group sessions costing $30. Other health care professionals have a copay between $0 and $10, and opioid treatment program services have a $20 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive services, including Medicare-covered preventive services, annual physical exams, and additional preventive services, are covered by the Clover Health Choice (PPO) plan. Health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $10 copay, as well as Routine Hearing Exams and Fitting/Evaluation for Hearing Aids. Prescription Hearing Aids (all types) are covered with a copay between $699 and $999, but Prescription Hearing Aids for the inner ear, outer ear, and over the ear are not covered, and OTC Hearing Aids are not covered.
Vision Services See details
Vision services include eye exams with a $10 copay. Eyewear is covered up to a combined maximum of $200 every year for both in-network and out-of-network services, and includes one pair of contact lenses and one pair of eyeglasses (lenses and frames) per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Clover Health Choice (PPO) covers dental services, including Medicare dental services with a $10 copay, and other dental services with a $2,000 maximum benefit per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, maxillofacial prosthetics, implant services, prosthodontics (fixed), and oral and maxillofacial surgery are covered with a $20 copay. Prosthodontics (removable) has a 50% coinsurance, while orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Clover Health Choice (PPO) plan with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered by Clover Health Choice (PPO), including Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetics/Medical Supplies, with a 20% coinsurance for Medicare-covered devices and supplies; however, Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. There is no copay for any of these services.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Clover Health Choice (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $200, while Lab Services have no copay. Diagnostic Radiological Services have a copay between $50 and $200, Therapeutic Radiological Services have 20% coinsurance, and Outpatient X-Ray Services have a $30 copay.
Home Health Services See details
Home Health Services are covered by the Clover Health Choice (PPO) plan with no copay or coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Clover Health Choice (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Clover Health Choice (PPO) plan, but require prior authorization. There is no copay for days 1-20, and a $214 copay per day for days 21-100.
Other Services See details
Other Services includes coverage for over-the-counter (OTC) items, with a maximum benefit of $110 every three months. Acupuncture, meal benefits, 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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