A non-government entity
Jefferson Health Plans Complete (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Complete (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 Complete (HMO) in 2026, please refer to our full plan details page.
Jefferson Health Plans Complete (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 Complete (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 Complete (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 Complete (HMO), 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.
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 $6500.00 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 Complete (HMO) plan features a $0 drug deductible, meaning your prescription drug coverage begins immediately. For Tier 1 preferred generic drugs, you will pay no copay for one-month, two-month, or three-month supplies filled through standard pharmacies or standard mail order. Tier 2 generic drugs are also highly affordable, costing a low $5 copay for a one-month supply and up to a $15 copay for a three-month supply. For higher-tier medications, this plan utilizes coinsurance rather than set copays. Tier 3 preferred brand drugs require a 25% coinsurance, while Tier 4 non-preferred drugs carry a 34% coinsurance for standard retail and mail-order fills. Specialty drugs in Tier 5 are covered at a 33% coinsurance for a one-month supply.
Additional Benefits
Jefferson Health Plans Complete (HMO) offers comprehensive medical coverage with predictable costs, featuring no copay and no coinsurance for primary care visits, preventive services, and home health care. Specialist visits require a low $25 copay, while emergency room visits carry a $100 copay that is waived if you are admitted. For inpatient hospital stays, members pay a $260 daily copay for days 1 through 7, with no copay required for days 8 through 90. Additional benefits include up to $2,250 in annual dental coverage and a $250 yearly allowance for eyewear with no copay. Routine hearing exams are available for a $35 copay, and members receive a $125 allowance every three months for over-the-counter items with no copay. Durable medical equipment is covered with no copay and a 20% coinsurance.
Inpatient Hospital See details
Jefferson Health Plans Complete (HMO) partially covers inpatient hospital services with no coinsurance, though prior authorization is required for acute and psychiatric stays. Covered stays require a $260 copay per day for days 1 through 7 and no copay for days 8 through 90, while additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Jefferson Health Plans Complete (HMO) covers outpatient services with no coinsurance, featuring a $250 copay for outpatient hospital and observation services and a $175 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $25 copay and no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Jefferson Health Plans Complete (HMO) with a $55.00 copay and no coinsurance, though prior authorization may be required.
Ambulance and Transportation Services See details
Ambulance and transportation services are offered by Jefferson Health Plans Complete (HMO), featuring a $250 copay and no coinsurance for ground ambulance, and a 20% coinsurance with no copay for air ambulance services. Prior authorization is required for all ambulance services, and routine transportation services to health-related locations are not covered.
Emergency Services See details
Jefferson Health Plans Complete (HMO) covers emergency services with a $100 copay and no coinsurance, and urgently needed services with a $10 copay and no coinsurance, with both copays waived if admitted 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 Complete (HMO) offers primary care physician services and select telehealth benefits with no copay and no coinsurance. Specialist visits, physical, occupational, speech, mental health, psychiatric, podiatry, and opioid treatment services require a $25 copay and no coinsurance, while chiropractic services are not covered.
Preventive Services See details
Jefferson Health Plans Complete (HMO) provides coverage for preventive services, including annual physicals, kidney disease education, and telemonitoring, with no copay and no coinsurance. However, additional preventive services are only partially covered, with sub-services like health education, nutritional therapy, and in-home support not covered by the plan.
Hearing Services See details
Jefferson Health Plans Complete (HMO) partially covers hearing services, offering routine hearing exams with a $35 copay, no deductible, and no coinsurance, as well as prescription hearing aids with a $500 to $1,975 copay and no coinsurance. However, hearing aid fitting and evaluations, OTC hearing aids, and inner, outer, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Jefferson Health Plans Complete (HMO) offers partially covered vision services, featuring one annual routine eye exam for a $45 copay and no coinsurance, though other eye exam services are not covered. Covered eyewear has no copay and no coinsurance, allowing up to $250 yearly for one pair of eyeglasses (lenses and frames) or unlimited contact lenses, but separate eyeglass lenses, separate frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered under Jefferson Health Plans Complete (HMO), with Medicare-covered dental requiring a $45 copay and no coinsurance, and other covered services having no copay and no coinsurance up to a $2,250 annual limit. Specific sub-services including fluoride treatment, adjunctive general services, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Jefferson Health Plans Complete (HMO) covers home infusion bundled services with no copay and no coinsurance, with prior authorization required. Associated Medicare Part B drugs, including chemotherapy and insulin, are covered with a copay ranging from no copay to $35 and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis services are covered by Jefferson Health Plans Complete (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Jefferson Health Plans Complete (HMO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay and 20% coinsurance, though diabetic supplies can range from no coinsurance to 20% coinsurance. Prior authorization is required for these benefits, and coverage may be limited to preferred vendors or manufacturers.
Diagnostic and Radiological Services See details
Jefferson Health Plans Complete (HMO) partially covers diagnostic and radiological services, as lab services are not covered. Covered diagnostic procedures and tests have no copay or coinsurance, while outpatient X-rays require a $15 copay plus coinsurance, diagnostic radiological services require a copay starting at $250, and therapeutic radiological services require a copay and a minimum 20% coinsurance. Prior authorization is required for these services.
Home Health Services See details
Home health services are covered by Jefferson Health Plans Complete (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Jefferson Health Plans Complete (HMO) offers Cardiac Rehabilitation Services with no copay and no coinsurance. While some services are covered, specific sub-services including Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Jefferson Health Plans Complete (HMO) with no coinsurance and no prior three-day inpatient hospital stay required. Stays require prior authorization and feature no copay for days 1 through 20, followed by a $175 daily copay for days 21 through 100.
Other Services See details
Jefferson Health Plans Complete (HMO) partially covers other services, offering up to 10 acupuncture treatments per year for a $10 copay and no coinsurance, as well as over-the-counter items with no copay and no coinsurance up to $125 every three months. Meal benefits are not covered under this plan.
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