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Clover Health Valor (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Clover Health Valor (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Clover Health Valor (PPO) in 2025, please refer to our full plan details page.
Clover Health Valor (PPO) is a PPO plan offered by Clover Health Holdings, Inc. available for enrollment in 2025 to people living in Select NJ and PA Counties. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Clover Health Valor (PPO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Clover Health Valor (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 Valor (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 $125.00. 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.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
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
Prescription drugs are not covered by Clover Health Valor (PPO).
Additional Benefits
The Clover Health Valor (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have copays, with no copay for days 7-90, while outpatient services, partial hospitalization, and medical equipment have coinsurance. Emergency services have copays, while primary care visits have no copay, but specialist visits do. Preventive services, including hearing and vision services, are covered with copays and maximum benefits. Dental services are covered with copays and a yearly maximum. Home health services, skilled nursing facility, and home infusion bundled services are covered, some with copays and coinsurance, and some with no copay.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you'll pay a $399 copay for days 1-6, and no copay for days 7-90. For Inpatient Hospital Psychiatric services, you'll pay a $335 copay for days 1-6, and no copay for days 7-90. Additional Days for Inpatient Hospital-Acute are 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 includes coverage for Outpatient Hospital Services and Observation Services with a 20% coinsurance, Ambulatory Surgical Center (ASC) Services with a 20% coinsurance, and Outpatient Substance Abuse Services with a $45 copay for individual sessions and a $35 copay for group sessions. Outpatient Blood Services are covered with a 20% coinsurance, and the plan waives the three (3) pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered by the Clover Health Valor (PPO) plan, but requires prior authorization. You will pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Clover Health Valor (PPO) plan. Ground and Air Ambulance Services have a $350 copay, but 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. Emergency Services and Worldwide Emergency Coverage have a $110 copay, Urgently Needed Services have a $25 copay, Worldwide Urgent Coverage has a $40 copay, and Worldwide Emergency Transportation has a $350 copay. Worldwide Emergency Services has a maximum plan benefit coverage of $50,000.
Primary Care See details
The Clover Health Valor (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy with a $35 copay, and specialist visits with a $50 copay. Mental health specialty services, psychiatric services, and other health care professional visits have varying copays depending on the service. Physical therapy and speech-language pathology services have a $35 copay, while additional telehealth benefits range from no copay to a $50 copay. Opioid treatment program services are covered with a $35 copay.
Preventive Services See details
Preventive services, including annual physical exams, are covered by the Clover Health Valor (PPO) plan. Additional preventive services include Fitness Benefit and Remote Access Technologies, while services such as Health Education, In-Home Safety Assessment, and others are not covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $50 copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $699 and $999, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
The Clover Health Valor (PPO) plan covers vision services, including eye exams with a $50 copay. Eyewear is covered up to a combined maximum of $200 every year for both in-network and out-of-network services, and includes one pair of contact lenses and one pair of eyeglasses (lenses and frames) per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Clover Health Valor (PPO) plan covers Medicare dental services with a $50 copay, and other dental services with a $1,500 maximum benefit per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, maxillofacial prosthetics, implant services, prosthodontics (fixed), and oral and maxillofacial surgery are covered with a $20 copay, and prosthodontics (removable) with a 50% coinsurance, all with a limit of 1 visit per year. Orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Clover Health Valor (PPO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered by the Clover Health Valor (PPO) plan, with a 20% coinsurance for Durable Medical Equipment, Prosthetic Devices, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Clover Health Valor (PPO) plan, with all diagnostic services requiring prior authorization. Diagnostic Procedures/Tests have a copay between $0 and $250, while Lab Services have no copay. Diagnostic Radiological Services have a copay between $50 and $250, Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $40 copay.
Home Health Services See details
Home Health Services are covered by the Clover Health Valor (PPO) plan with no copay and no coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover any of the sub-services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Clover Health Valor (PPO) plan, 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 and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) items, with a maximum benefit of $50 every three months. 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.
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