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.
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 $13300.00 (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 $13300.00 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 drug coverage begins immediately with no upfront deductible costs. Under this plan, Tier 1 preferred generic drugs have no copay for 1-month, 2-month, or 3-month supplies at standard pharmacies, as well as for 3-month standard mail orders. Tier 2 generic drugs carry an $8 copay for a 1-month supply at standard pharmacies, but you can obtain a 3-month supply with no copay through standard mail order. For brand-name and specialty medications, costs vary depending on the drug tier and supply duration. Tier 3 preferred brand drugs require a standard pharmacy copay of $47 for a 1-month supply, while Tier 4 non-preferred drugs cost a $100 copay. Tier 5 specialty drugs require a 33% coinsurance for all supply lengths at both standard pharmacies and standard mail order.
Additional Benefits
The Clover Health Choice (PPO) Medicare plan offers comprehensive medical coverage with predictable out-of-pocket costs, featuring no copay and no coinsurance for primary care visits and preventive services. If you require specialist care, visits are available for a low $10 copay, while emergency room visits carry a $115 copay that is waived if you are admitted. For hospital stays, inpatient care requires a $399 daily copay for the first six days followed by no copay for additional days, while outpatient hospital services require a $390 copay. This plan also includes valuable supplemental benefits, such as routine dental care with no copay and a $1,500 annual maximum, alongside routine vision and hearing exams for a $10 copay. Additionally, members receive a $300 annual eyewear allowance and a quarterly $100 over-the-counter reimbursement benefit with no copays. Skilled nursing facility care is also covered with no copay for the first 20 days, helping you manage your recovery costs effectively.
Inpatient Hospital See details
Clover Health Choice (PPO) covers inpatient acute hospital stays with no coinsurance and a $399 daily copay for days 1 to 6, followed by no copay for days 7 to 90 and unlimited additional days. Inpatient psychiatric stays are also covered with no coinsurance and a $339 daily copay for days 1 to 6, though additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Clover Health Choice (PPO) covers outpatient services with no coinsurance, featuring a $390 copay for outpatient hospital and observation services and a $250 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $35 to $45 copay, while outpatient blood services are covered with no copay, coinsurance, or deductible.
Partial Hospitalization See details
Clover Health Choice (PPO) covers partial hospitalization services with a $70 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Clover Health Choice (PPO) partially covers Ambulance and Transportation Services, offering Medicare-covered ground and air ambulance services for a $350 copay and no coinsurance, with prior authorization required. Transportation services to plan-approved or any 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 $40 copay, both featuring no coinsurance and waived copays if admitted to the hospital within 24 hours. Worldwide emergency, urgent, and transportation services are also covered up to a $50,000 maximum 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 for a $10 copay and no coinsurance. Additional covered benefits include physical and occupational therapy ($25 copay), mental health services ($35 to $45 copay), and telehealth (no copay to a $10 copay), all with no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Clover Health Choice (PPO) covers preventive services, including annual physical exams, kidney disease education, and select screenings, with no copay and no coinsurance. Additional preventive services are partially covered with no copay and no coinsurance, but do not cover health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge 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, additional smoking cessation, enhanced disease management, telemonitoring, home safety modifications, or counseling.
Hearing Services See details
Hearing services are partially covered by Clover Health Choice (PPO), featuring a $10 copay and no coinsurance for routine annual hearing exams and unlimited fitting evaluations. Up to two prescription hearing aids are covered per year with no coinsurance and a copayment ranging from $499 to $999, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Clover Health Choice (PPO), featuring routine eye exams for a $10 copay and no coinsurance, while other eye exams, separate eyeglass lenses, frames, and upgrades are not covered. Covered eyewear, including one pair of contacts or eyeglasses per year, has no copay or coinsurance and is subject to a combined annual maximum of $300.
Dental Services See details
Dental services are partially covered by Clover Health Choice (PPO) with a maximum annual benefit of $1,500, though orthodontics is not covered. Preventive care has no copay and no coinsurance, Medicare-covered services cost a $10.00 copay and no coinsurance, and comprehensive services require either a $20.00 copay and no coinsurance or, for removable prosthodontics, no copay and 50% coinsurance.
Home Infusion bundled Services See details
Clover Health Choice (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy may apply. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs feature no copay and a coinsurance ranging from 0% to 20%.
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
Clover Health Choice (PPO) covers medical equipment, offering durable medical equipment and prosthetics with no copay and a 20% coinsurance. Diabetic equipment is partially covered with no copay and no coinsurance, though diabetic supplies and diabetic 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. Diagnostic tests have a $0 to $200 copay with no coinsurance, lab services have no copay or coinsurance, and outpatient X-rays require a $40 copay. Diagnostic radiological services require a minimum $50 copay, while therapeutic radiological services carry a minimum 20% coinsurance.
Home Health Services See details
Clover Health Choice (PPO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Clover Health Choice (PPO) covers some cardiac rehabilitation services with no coinsurance, but requires prior authorization. While some services are covered, cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered, with copayments ranging from $15 to $20.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by Clover Health Choice (PPO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior 3-day hospital stay is not required, and additional days beyond the Medicare-covered 100 days are not covered.
Other Services See details
Other services are partially covered by Clover Health Choice (PPO), which provides an over-the-counter (OTC) benefit of up to $100 every three months through reimbursement with no copay and no coinsurance. Acupuncture, meal benefits, and nicotine replacement therapy are not covered under this plan.
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