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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 $56.90. 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 $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:
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Drug Coverage
The Clover Health Choice Value (PPO) plan has a $150 deductible for prescription drugs. After the deductible, you will pay either a copay or coinsurance depending on the drug tier and pharmacy used. For example, in the initial coverage phase at a standard pharmacy, you will pay an $8 copay for tier 1 preferred generic drugs, 25% coinsurance for tier 2 standard generic drugs, 35% coinsurance for tier 3 preferred brand drugs, and 31% coinsurance for tier 4 non-preferred drugs. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Clover Health Choice Value (PPO) plan offers coverage for a variety of services with varying cost-sharing. Inpatient hospital stays have copays depending on the type of stay and the length of stay, and outpatient services have copays ranging from $0 to $400. The plan also covers emergency services, primary care, preventive services, hearing, vision, and dental services, each with its own cost structure, including copays and coinsurance. Additional benefits include home health services with no copay, durable medical equipment with 20% coinsurance, and over-the-counter items with a quarterly allowance. However, some services like cardiac rehabilitation, certain hearing aids, and some vision and dental services are not covered or have limitations. Be sure to review the details of each benefit to understand your potential out-of-pocket costs.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. 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. Additional Days for Inpatient Hospital-Acute is covered with no copay. Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $400, observation services with a $400 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with 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, but requires prior authorization. The copay for this benefit is $80.
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, and there is no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Clover Health Choice Value (PPO) plan with a $110 copay, and no coinsurance. Urgently Needed Services have a $35 copay and no coinsurance, while Worldwide Emergency Coverage has a $110 copay, Worldwide Urgent Coverage has a $40 copay, and Worldwide Emergency Transportation has a $350 copay – all with no coinsurance.
Primary Care See details
The Clover Health Choice Value (PPO) plan covers primary care physician services, chiropractic services with a $10 copay, occupational therapy with a $15 copay, physician specialist services with a $2 copay, mental health specialty services with a copay between $10 and $20 depending on the service, other health care professionals with a copay between $0 and $2, psychiatric services with a copay between $10 and $20 depending on the service, physical therapy and speech-language pathology services with a $15 copay, additional telehealth benefits with a copay between $0 and $2, and opioid treatment program services with a $10 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Clover Health Choice Value (PPO) plan covers preventive services, including annual physical exams, with no copay. Additional preventive services, such as health education, in-home safety assessments, and medical nutrition therapy, are not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $2 copay and fitting/evaluation for hearing aids. Prescription hearing aids are covered with a copay between $699 and $999, while 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 are covered by Clover Health Choice Value (PPO), including eye exams with a $2 copay, contact lenses (1 pair per year), and eyeglasses (lenses and frames) (1 pair per year) with a combined maximum of $100 per year for both in-network and out-of-network services; however, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are covered, with a $1,500 annual maximum benefit. The plan has a $2 copay for Medicare dental services, $20 copay for restorative services, and $20 copay for adjunctive general services, endodontics, periodontics, maxillofacial prosthetics, implant services, prosthodontics fixed, and oral and maxillofacial surgery. Prosthodontics removable has a 50% coinsurance. Other services, such as oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, and other preventive dental services are limited to 1 or 2 visits per year. 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 a coinsurance between 0% and 20%. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the Clover Health Choice Value (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. 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 are covered, including Diagnostic Procedures/Tests with a copay between $0 and $200, Lab Services with no copay, Diagnostic Radiological Services with a copay between $50 and $200, Therapeutic Radiological Services with 20% coinsurance, and Outpatient X-Ray Services with a $30 copay. All services require prior authorization.
Home Health Services See details
Home Health Services are covered by the Clover Health Choice Value (PPO) plan, with no copay or coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Clover Health Choice Value (PPO) plan. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by Clover Health Choice Value (PPO), but require prior authorization. For days 1-20, there is no copay, and for days 21-100, there is a $214 copay. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services for Clover Health Choice Value (PPO) include coverage for Over-the-Counter (OTC) items with a maximum plan benefit of $125 every three months, but acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, and many additional services are not covered. Nicotine Replacement Therapy (NRT) is not covered, but Naloxone coverage is available.
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