A non-government entity
Clover Health Premier (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Clover Health Premier (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Clover Health Premier (PPO) in 2025, please refer to our full plan details page.
Clover Health Premier (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 Premier (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 Premier (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 Premier (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 $100.00. 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 $200.00 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 $12999.00 (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 $12999.00 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 Premier (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Clover Health Premier (PPO) plan has a $200 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, you may pay an $8 copay for a Tier 1 drug at a standard pharmacy. You will pay 19% coinsurance for a Tier 2 drug at a standard pharmacy, and 34% coinsurance for a Tier 3 drug at a standard pharmacy.
Additional Benefits
The Clover Health Premier (PPO) plan offers a range of benefits with varying costs. For inpatient hospital stays, you'll pay a copay that varies depending on the type of care and the number of days. Outpatient services, including primary care, have copays that typically range from $15-$45. Preventive services, like annual physical exams, have no copay. The plan also covers hearing and vision services, with copays for exams and coverage for eyewear and hearing aids. Other covered services include ambulance, emergency services, and home health services, with specific copays or coinsurance depending on the service.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you pay a $350 copay for days 1-6, and no copay for days 7-90; for Inpatient Hospital Psychiatric, you pay a $320 copay for days 1-6, and no copay for days 7-90. Additional days for Inpatient Hospital-Acute are covered, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered, as well as Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services and observation services have a $450 copay, ambulatory surgical center services have a $350 copay, and outpatient substance abuse services have a copay of $45 for individual sessions and $35 for group sessions. Outpatient blood services have a three-pint deductible waived.
Partial Hospitalization See details
Partial Hospitalization is covered by the Clover Health Premier (PPO) plan, but requires prior authorization. You will have a $70 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Clover Health Premier (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 under the Clover Health Premier (PPO) plan. Emergency Services have a $100 copay, Urgently Needed Services have a $40 copay, and Worldwide Emergency Coverage has a $100 copay, Worldwide Urgent Coverage has a $40 copay, and Worldwide Emergency Transportation has a $350 copay.
Primary Care See details
The Clover Health Premier (PPO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, physician specialist services with a $35 copay, mental health specialty services with a copay of $45 for individual sessions and $35 for group sessions, other health care professional services with a copay between $0 and $35, psychiatric services with a copay of $45 for individual sessions and $35 for group sessions, physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits with a copay between $0 and $35, and opioid treatment program services with a $35 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Clover Health Premier (PPO) plan covers preventive services, including an annual physical exam, with no copay. Additional preventive services like fitness benefits, remote access technologies, and kidney disease education services are covered, with no copay. However, health education, in-home safety assessments, and other services are not covered.
Hearing Services See details
Hearing Services are covered by the Clover Health Premier (PPO) plan, including routine hearing exams with a $35 copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a copay between $699 and $999. 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 $35 copay. Eyewear benefits are also covered, with a combined maximum plan benefit of $200 every year for both in-network and out-of-network services, and includes coverage for contact lenses (1 pair per year) and eyeglasses (lenses and frames, 1 pair per year). Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Clover Health Premier (PPO) plan covers Medicare Dental Services with a $35 copay, and it also covers other dental services including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, and other preventive dental services. Orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and oral and maxillofacial surgery are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B insulin drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered, with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis services are covered under the Clover Health Premier (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 - Non-Medicare benefit with coinsurance, and Diabetic Equipment; however, Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. Additionally, there is no copay for any of these services.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Clover Health Premier (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $350, and Lab Services have no copay. Diagnostic Radiological Services have a copay between $50 and $350, while Therapeutic Radiological Services have a 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 Premier (PPO) plan with no copay and no coinsurance; however, additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but not in practice. 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 Premier (PPO) plan, with a $0 copay for days 1-20, and a $203 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services for the Clover Health Premier (PPO) plan covers Over-the-Counter (OTC) Items, with a maximum benefit coverage amount of $50.00 every three months, but Acupuncture, Meal Benefit, 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.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved