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Jefferson Health Plans Prime (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Prime (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Jefferson Health Plans Prime (HMO) in 2026, please refer to our full plan details page.
Jefferson Health Plans Prime (HMO) is a HMO plan offered by Thomas Jefferson University available for enrollment in 2025 to people living in Southeastern PA, Central PA and Eastern PA. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Jefferson Health Plans Prime (HMO) 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 Jefferson Health Plans Prime (HMO).
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 Jefferson Health Plans Prime (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $32.70. 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 Maximum Out-Of-Pocket cost of $6000.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
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 Jefferson Health Plans Prime (HMO) plan features a $0 drug deductible, meaning your prescription drug coverage begins immediately. Under this plan, you will pay no copay for Tier 1 preferred generic drugs for one, two, or three-month supplies at standard pharmacies or through standard mail order. Tier 2 generic drugs carry a $10 copay for a one-month supply, with standard mail order offering a cost-saving $20 copay for a three-month supply. For brand-name and specialty medications, costs are based on a percentage of the drug cost. Tier 3 preferred brands require a 25% coinsurance and Tier 4 non-preferred drugs require a 28% coinsurance. Tier 5 specialty drugs are available in a one-month supply with a 33% coinsurance at standard pharmacies and through standard mail order.
Additional Benefits
Jefferson Health Plans Prime (HMO) features comprehensive healthcare coverage with no copay for primary care visits and preventive services. Specialist visits, physical therapies, and mental health sessions require a $20 copay, while emergency care is covered with a $100 copay that is waived if you are admitted to the hospital. Outpatient hospital stays carry a $350 copay, and inpatient hospital care is covered with daily copays for the initial days of a stay and no copay for days 7 through 90. This plan also provides robust supplemental benefits, including up to $2,250 in annual dental coverage with no copay for preventive services like cleanings and exams. Vision benefits include up to $300 yearly for eyeglasses with no copay, while routine hearing exams require a $35 copay. Additionally, members benefit from a $130 quarterly over-the-counter allowance and up to 25 one-way trips per year to health-related locations with no copay.
Inpatient Hospital See details
Jefferson Health Plans Prime (HMO) partially covers inpatient hospital services with no coinsurance, though prior authorization is required. Covered acute and psychiatric stays require daily copays for the initial days of a stay and no copay for days 7 through 90, while additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Jefferson Health Plans Prime (HMO) covers outpatient services with no coinsurance, including outpatient hospital and observation services for a $350 copay per stay, and ambulatory surgical center services for a $300 copay. Outpatient substance abuse sessions require a $20 copay, while outpatient blood services are covered with no copay.
Partial Hospitalization See details
Jefferson Health Plans Prime (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance, although prior authorization is required.
Ambulance and Transportation Services See details
Jefferson Health Plans Prime (HMO) covers ground ambulance services with a $240 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Transportation services are partially covered, offering up to 25 one-way trips per year to plan-approved health-related locations with no copay and no coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
Jefferson Health Plans Prime (HMO) covers emergency services with a $100 copay and no coinsurance, and urgently needed services with a $5 copay and no coinsurance, with both copays waived if you are admitted to the hospital within 24 hours. Worldwide emergency and urgent services are partially covered up to a $50,000 maximum with no copay or coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Jefferson Health Plans Prime (HMO) provides primary care physician services with no copay and no coinsurance, while specialist visits, therapies, mental health, podiatry, and opioid treatment services require a $20 copay and no coinsurance. Telehealth and other health professional services feature copays ranging from $0 to $20 with no coinsurance, but chiropractic services are not covered.
Preventive Services See details
Jefferson Health Plans Prime (HMO) covers preventive services with no copay and no coinsurance, including annual physical exams, kidney disease education, memory fitness, and telemonitoring. This benefit is partially covered, as 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 counseling, enhanced disease management, remote access technologies, home safety devices, and counseling services are not covered.
Hearing Services See details
Hearing services are partially covered by Jefferson Health Plans Prime (HMO), offering one routine hearing exam per year for a $35 copay and no coinsurance, while fitting evaluations and OTC hearing aids are not covered. Prescription hearing aids are covered once every two years with a copay ranging from $500.00 to $1,975.00 and no coinsurance, though inner ear, outer ear, and over-the-ear options are excluded.
Vision Services See details
Jefferson Health Plans Prime (HMO) offers partially covered vision services, which include one annual routine eye exam for a $40 copay and no coinsurance, though other eye exam services are not covered. Covered eyewear has no copay and no coinsurance, providing unlimited contact lenses and up to $300 yearly for a pair of eyeglasses, while individual eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Jefferson Health Plans Prime (HMO) partially covers dental services with an annual maximum benefit of $2,250, offering Medicare-covered dental services for a $40 copay and no coinsurance. Other covered services, including oral exams, cleanings, x-rays, restorative, endodontics, periodontics, prosthodontics, and oral surgery, are available with no copay and no coinsurance. Fluoride treatment, adjunctive general services, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Jefferson Health Plans Prime (HMO) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs require no copay and range from no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and range from no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by Jefferson Health Plans Prime (HMO) with a 20% coinsurance and no copay.
Medical Equipment See details
Jefferson Health Plans Prime (HMO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic shoes, with no copay and 20% coinsurance. Diabetic supplies are also covered with no copay and coinsurance ranging from no coinsurance to 20%, with prior authorization required across these benefits.
Diagnostic and Radiological Services See details
Jefferson Health Plans Prime (HMO) diagnostic and radiological services are partially covered, as lab services are not covered and prior authorization is required. Diagnostic procedures and tests have no copay and no coinsurance, while radiological services require a $25 copay for X-rays, a minimum $250 copay for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered by Jefferson Health Plans Prime (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Jefferson Health Plans Prime (HMO) covers some services under Cardiac Rehabilitation Services with no copay and no coinsurance, but cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Jefferson Health Plans Prime (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $170 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not needed, and additional days beyond the standard 100 days are not covered.
Other Services See details
Jefferson Health Plans Prime (HMO) partially covers other services, offering acupuncture up to 20 treatments per year and a $130 quarterly over-the-counter reimbursement with no copay and no coinsurance. Meal benefits and Naloxone are not covered under this plan.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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