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Clover Health Choice Value (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Clover Health Choice Value (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 Value (PPO) in 2025, please refer to our full plan details page.
Clover Health Choice Value (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 Value (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 Value (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 Value (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $48.30. 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 a $220.00 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:
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Drug Coverage
The Clover Health Choice Value (PPO) plan has an enhanced alternative drug benefit. The plan has a $220 deductible. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. In the initial coverage phase, you may pay a $5 copay for preferred generic drugs at a standard pharmacy. Standard generic drugs have a $47 copay, and preferred brand drugs have a 35% coinsurance. Non-preferred drugs have a 30% coinsurance. After your total drug costs reach $2000, you will enter the catastrophic coverage phase where you will pay nothing for covered drugs.
Additional Benefits
The Clover Health Choice Value (PPO) plan offers coverage for a variety of healthcare services. It includes inpatient hospital stays with copays, outpatient services with copays, and emergency services with copays. The plan also covers primary care, preventive services, hearing, vision, and dental services, with varying copays and coverage limits. This plan provides additional benefits such as home health services with no copay, dialysis services with 20% coinsurance, and medical equipment with 20% coinsurance. You can also get coverage for home infusion, skilled nursing facilities, and other services like over-the-counter items. Some services, such as cardiac rehabilitation and certain vision and dental services, are not covered.
Inpatient Hospital See details
The Clover Health Choice Value (PPO) plan covers inpatient hospital stays, including acute and psychiatric care. For Inpatient Hospital-Acute, you have a $399 copay for days 1-6, and no copay for days 7-90. For Inpatient Hospital Psychiatric, you have a $339 copay for days 1-6, and no copay for days 7-90. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient services, including outpatient hospital services and observation services, have a $250 copay. Ambulatory Surgical Center (ASC) services have a $175 copay, while outpatient substance abuse services have a $20 copay for individual sessions and a $10 copay for group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Clover Health Choice Value (PPO) plan, with a $80 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Clover Health Choice Value (PPO) plan. Ground and Air Ambulance Services have a $350 copay, with no coinsurance, while 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 Clover Health Choice Value (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, Urgently Needed Services have a $35 copay, Worldwide Urgent Coverage has a $40 copay, and Worldwide Emergency Transportation has a $350 copay. There is no coinsurance for any of these services.
Primary Care See details
The Clover Health Choice Value (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 $5 copay, while physician specialist services have a $2 copay. Individual and group sessions for mental health and psychiatric services have copays of $20 and $10 respectively, and other health care professionals have a copay between $0 and $2. Physical therapy and speech-language pathology services have a $5 copay, and opioid treatment program services have a $10 copay. Additional telehealth benefits have a copay between $0 and $2. Routine Chiropractic Care is not covered.
Preventive Services See details
Preventive services, including annual physical exams, are covered by the Clover Health Choice Value (PPO) plan. Additional services like Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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 Benefit, 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 $2 copay, and routine hearing exams covered for 1 visit every year. Prescription hearing aids are covered with a copay between $699 and $999, but Prescription Hearing Aids - 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 coverage for eye exams with a $2 copay, and eyewear, including contact lenses and eyeglasses (lenses and frames). The plan covers one pair of contact lenses and one pair of eyeglasses (lenses and frames) per year, with a combined maximum of $200 for eyewear. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $2 copay, and other dental services with a $2,500 maximum benefit per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, and other preventive dental services are covered. Restorative services, adjunctive general services, endodontics, periodontics, maxillofacial prosthetics, implant services, prosthodontics (fixed), and oral and maxillofacial surgery have a $20 copay, while prosthodontics (removable) has a 50% coinsurance. Orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Clover Health Choice Value (PPO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered under the Clover Health Choice Value (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, and Prosthetic Devices and Medical Supplies have a 20% coinsurance. Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for diagnostic procedures/tests with a copay between $0 and $175, lab services with no copay, and outpatient X-ray services with a $15 copay. Therapeutic Radiological Services have a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Clover Health Choice Value (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Clover Health Choice Value (PPO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $170 every three months, but acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and other services are not covered. The plan does not cover all of the drugs on the CMS OTC list.
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