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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 2025, 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 2025.
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 $40.90. 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6400.00 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 has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay either a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, if you use a standard pharmacy, you will pay a $10 copay for Tier 1 drugs, or 25% coinsurance for Tier 2 drugs. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. If you qualify for the low-income subsidy, your monthly premium will be $40.90.
Additional Benefits
The Jefferson Health Plans Prime (HMO) plan offers a variety of benefits with varying cost-sharing. This plan covers inpatient hospital stays with a copay, and also includes outpatient services, emergency services, primary care, and preventive services. Additional benefits include hearing and vision services, dental, home infusion, dialysis, medical equipment, and home health services. The plan also provides coverage for ambulance and transportation services, skilled nursing facilities, and other services like acupuncture and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a copay of $235 for days 1-6, and no copay for days 7-90. Inpatient Hospital Psychiatric benefits are also covered, with the same cost sharing structure. Additional days, non-Medicare covered stays, and upgrades for both inpatient hospital and inpatient psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a $350 copay, observation services with a $350 copay per stay, and ambulatory surgical center services with a $300 copay. Outpatient substance abuse services are covered with a $20 copay for both individual and group sessions, but outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Jefferson Health Plans Prime (HMO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
The Jefferson Health Plans Prime (HMO) plan covers ambulance and transportation services, including ground and air ambulance. Ground ambulance services have a $250 copay, while air ambulance services have a 20% coinsurance. Transportation services to a plan-approved health-related location are covered for up to 50 one-way trips per year, but 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 Jefferson Health Plans Prime (HMO) plan. Emergency Services have a $100 copay and no coinsurance, while Urgently Needed Services have a $5 copay and no coinsurance; Worldwide Emergency Services has a maximum plan benefit coverage of $50,000. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Jefferson Health Plans Prime (HMO) plan covers primary care physician services, occupational therapy services, physician specialist services, mental health specialty services (with a $20 copay for individual and group sessions), podiatry services (with a $20 copay), other health care professional services (with a copay between $0 and $20), psychiatric services (with a $20 copay for individual and group sessions), physical therapy and speech-language pathology services (with a $20 copay), additional telehealth benefits (with a copay between $0 and $20), and opioid treatment program services (with a $20 copay). Chiropractic services are covered, but routine care is not covered, and there is a $15 copay for other services.
Preventive Services See details
The Jefferson Health Plans Prime (HMO) plan covers preventive services, including annual physical exams and additional preventive services like fitness benefits and telemonitoring services. Health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, remote access technologies, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing Services includes routine hearing exams with a $35 copay, but does not cover fitting/evaluation for hearing aids, prescription hearing aids, or OTC hearing aids. You are limited to one routine hearing exam per year.
Vision Services See details
Vision Services includes coverage for eye exams with a $40 copay. Eyewear is partially covered, with coverage for contact lenses and eyeglasses (lenses and frames), but not for eyeglass lenses, eyeglass frames, or upgrades.
Dental Services See details
The Jefferson Health Plans Prime (HMO) plan covers Medicare Dental Services with a $40 copay, and covers Oral Exams (3 visits per year), Dental X-Rays (1 per year), Other Diagnostic Dental Services, Prophylaxis (Cleaning) (3 visits per year), Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, and Oral and Maxillofacial Surgery. Fluoride Treatment, Adjunctive General Services, Implant Services, and Orthodontics are 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. For Medicare Part B Insulin Drugs, there is a $35 copay with coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Jefferson Health Plans Prime (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetics/Medical Supplies with a 20% coinsurance, while Diabetic Supplies have a coinsurance between 0% and 20%, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. 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 Jefferson Health Plans Prime (HMO) plan. Diagnostic Procedures/Tests have a $10 copay, while Lab Services are not covered; Diagnostic Radiological Services have a $250 copay, Therapeutic Radiological Services have 20% coinsurance, and Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by the Jefferson Health Plans Prime (HMO) plan with no copay and no 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 Jefferson Health Plans Prime (HMO) plan. Specifically, Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Jefferson Health Plans Prime (HMO) plan. For days 1-20, there is no copay, and for days 21-100, the copay is $203. Additional days beyond Medicare-covered, and non-Medicare-covered SNF stays are not covered.
Other Services See details
The Jefferson Health Plans Prime (HMO) plan covers acupuncture with a limit of 20 treatments per year, and over-the-counter (OTC) items up to $165 every three months, including nicotine replacement therapy. 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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