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 San Antonio Area. 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.
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 $6350.00 (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 $6350.00 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 features a $0 drug deductible, meaning your prescription coverage begins immediately. For Tier 1 preferred generic drugs, you pay no copay for a 1-month, 2-month, or 3-month supply at standard pharmacies, as well as no copay for a 3-month standard mail-order supply. Tier 2 generic drugs cost $8 for a 1-month supply at standard pharmacies, with no copay if you choose a 3-month standard mail-order option. For Tier 3 preferred brand drugs, standard pharmacy copays start at $47 for a 1-month supply, while Tier 4 non-preferred drugs have a $100 copay for a 1-month supply. Both Tier 3 and Tier 4 medications offer a 3-month standard mail-order option for $135 and $300, respectively. Tier 5 specialty drugs require a 33% coinsurance for all available supply durations at both standard pharmacies and standard mail order.
Additional Benefits
The Clover Health Choice (PPO) plan offers cost-effective coverage with no copay and no coinsurance for primary care, specialist visits, telehealth, and preventive services. For inpatient hospital stays, members pay a daily copay of $225 for the first six days and no copay for days 7 through 90. Outpatient hospital services require a $300 copay, while emergency room visits carry a $130 copay that is waived if you are admitted. Members also benefit from routine dental, vision, and hearing exams with no copay, plus a $1,500 annual dental limit and $200 yearly eyewear allowance. Over-the-counter items are covered with no copay up to a $60 quarterly reimbursement, and prescription hearing aids carry a copay between $499 and $999. Durable medical equipment and dialysis services are covered with no copay and a 20% coinsurance.
Inpatient Hospital See details
Clover Health Choice (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $225 daily copay for days 1 through 6 and no copay for days 7 through 90. Unlimited additional acute care days are covered with no copay, but upgrades, additional psychiatric days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Clover Health Choice (PPO) covers outpatient hospital and observation services with a $300 copay and no coinsurance, and ambulatory surgical center services with a $175 copay and no coinsurance. Outpatient substance abuse services are covered with no coinsurance and a copay of $30 for individual sessions or $20 for group sessions, while outpatient blood services have no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by Clover Health Choice (PPO) with an $80 copay and no coinsurance, though prior authorization may be required.
Ambulance and Transportation Services See details
Clover Health Choice (PPO) covers ground and air ambulance services with a $350 copay and no coinsurance, though prior authorization is required. Transportation services are not covered.
Emergency Services See details
Clover Health Choice (PPO) covers emergency services with a $130 copay and urgently needed services with a $25 copay, both with no coinsurance and copays waived if admitted to the hospital within 24 hours. Worldwide emergency services are also covered up to a $50,000 maximum with no coinsurance, carrying a $130 copay for emergency care, a $40 copay for urgent care, and a $350 copay for emergency transportation.
Primary Care See details
Clover Health Choice (PPO) provides primary care, specialist visits, and telehealth services with no copay and no coinsurance, while physical, occupational, and speech therapies require a $20 copay and no coinsurance. Mental health and psychiatric individual sessions carry a $30 copay and group sessions a $20 copay with no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
Clover Health Choice (PPO) provides partially covered preventive services with no copay and no coinsurance for covered benefits like annual physical exams, kidney disease education, memory fitness, and select screenings. Supplemental services such as health education, in-home safety assessments, personal emergency response systems, weight management, and nutritional counseling are not covered.
Hearing Services See details
Hearing services under Clover Health Choice (PPO) are covered with no copay or coinsurance for routine hearing exams and fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $499 to $999 for up to two aids per year, though over-the-counter, inner ear, outer ear, and over-the-ear models are not covered.
Vision Services See details
Vision services are partially covered by Clover Health Choice (PPO) with no copay and no coinsurance for one routine annual eye exam and eyewear, which includes a $200 yearly limit for one pair of glasses or contacts. Other eye exam services, individual eyeglass lenses, individual frames, and upgrades are not covered.
Dental Services See details
Clover Health Choice (PPO) offers partially covered dental services with an annual maximum benefit of $1,500 for both in-network and out-of-network care, though orthodontics is not covered. Preventive care is available with no copay and no coinsurance, while comprehensive services generally require a $20 copay and no coinsurance, except for removable prosthodontics which has no copay and 50% coinsurance.
Home Infusion bundled Services See details
Clover Health Choice (PPO) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Under this benefit, Medicare Part B insulin has a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Clover Health Choice (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Clover Health Choice (PPO) with no copay, requiring a 20% coinsurance and prior authorization for durable medical equipment, prosthetics, and medical supplies. Diabetic equipment is partially covered with no copay and no coinsurance, though diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Clover Health Choice (PPO) with prior authorization required. Lab services have no copay and no coinsurance, while diagnostic tests range from no copay to a $175 copay with no coinsurance. Outpatient X-rays require a $30 copay, diagnostic radiology starts at a $50 copay, and therapeutic radiology services require a minimum 20% coinsurance.
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 by Clover Health Choice (PPO) with no coinsurance, though some services are covered while standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for peripheral artery disease are not covered. These services require prior authorization and carry copayments ranging from $15 to $20.
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 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 standard Medicare 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 $60 every three months via reimbursement. Acupuncture and meal benefits are not covered under this plan.
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