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Jefferson Health Plans Silver (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Silver (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 Silver (HMO) in 2026, please refer to our full plan details page.
Jefferson Health Plans Silver (HMO) is a HMO plan offered by Thomas Jefferson University available for enrollment in 2025 to people living in Southern New Jersey. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Jefferson Health Plans Silver (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 Silver (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 Silver (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 Silver (HMO) prescription drug coverage features a $0 drug deductible, meaning your benefits begin immediately without any out-of-pocket deductible costs. Under this plan, Tier 1 preferred generic drugs have no copay for one-month, two-month, and three-month supplies at standard pharmacies and through standard mail order. Tier 2 generic drugs require a $10 copay for a one-month supply, a $20 copay for a two-month supply, and up to a $30 copay for a three-month supply. For brand-name and specialty medications, costs are determined by coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 25% coinsurance, while Tier 4 non-preferred drugs have a 32% coinsurance for standard retail and mail-order fills. Specialty drugs in Tier 5 are covered with a 33% coinsurance for a one-month supply.
Additional Benefits
Jefferson Health Plans Silver (HMO) provides strong core medical coverage with no copay and no coinsurance for primary care and preventive visits, while specialist consultations require a low $15 copay. Inpatient hospital stays feature no coinsurance, with a $250 copay for the first five days and no copay for days six through 90. Emergency services require a $100 copay, which is waived if you are admitted, and urgent care visits carry a $10 copay. In addition to medical care, the plan features dental and vision benefits with no copay for routine eyewear up to a $200 maximum and no copay for select dental services up to a $3,500 annual limit. Routine hearing exams require a $35 copay, while over-the-counter health items are covered with no copay up to $125 every three months. For specialized needs, home health services require no copay, while durable medical equipment and dialysis services generally carry a 20% coinsurance.
Inpatient Hospital See details
Jefferson Health Plans Silver (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $250 copay for days 1 through 5 and no copay for days 6 through 90. Prior authorization is required, and additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Jefferson Health Plans Silver (HMO) covers outpatient services with no coinsurance, featuring a $325 copay for outpatient hospital and observation services, and a $225 copay for ambulatory surgical center services. Outpatient substance abuse individual and group sessions require a $20 copay, while outpatient blood services are fully covered with no copay or deductible.
Partial Hospitalization See details
Partial hospitalization services are covered by Jefferson Health Plans Silver (HMO) with a $55.00 copay and no coinsurance. Prior authorization is required for some of these covered services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Jefferson Health Plans Silver (HMO), featuring a $225 copay and no coinsurance for ground ambulance services, and a 20% coinsurance with no copay for air ambulance services. Prior authorization is required for ambulance transport, costs are not waived if admitted to the hospital, and routine transportation services to health-related locations are not covered.
Emergency Services See details
Jefferson Health Plans Silver (HMO) covers emergency services with a $100 copay and no coinsurance, and urgently needed services with a $10 copay and no coinsurance, with copays waived if admitted within 24 hours. Worldwide emergency and urgent care are partially covered with no copay or coinsurance up to a $50,000 maximum, though worldwide emergency transportation is not covered.
Primary Care See details
Jefferson Health Plans Silver (HMO) provides primary care physician services with no copay and no coinsurance, alongside telehealth benefits featuring a $0 to $15 copay and no coinsurance. Specialist visits, physical therapy, mental health specialty services, and podiatry require a $15 copay and no coinsurance, though routine chiropractic services are not covered.
Preventive Services See details
Jefferson Health Plans Silver (HMO) covers preventive services, including annual physical exams and kidney disease education, with no copay and no coinsurance. However, these benefits are only partially covered, as additional services like health education, nutritional therapy, and personal emergency response systems are not covered.
Hearing Services See details
Hearing services are covered by Jefferson Health Plans Silver (HMO) with no deductible, requiring a $35 copay and no coinsurance for routine hearing exams. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $500.00 to $1,975.00 every two years, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Jefferson Health Plans Silver (HMO) vision services are partially covered, offering one routine eye exam per year with a $15 copay and no coinsurance, while other eye exam services are not covered. Covered eyewear includes unlimited contact lenses and one pair of eyeglasses (lenses and frames) per year up to a $200 maximum with no copay and no coinsurance, though individual eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Jefferson Health Plans Silver (HMO) partially covers dental services, offering Medicare-covered dental with a $15 copay and no coinsurance, and other covered dental services with no copay and no coinsurance up to a $3,500 annual maximum. Fluoride treatments, adjunctive general services, implant services, and orthodontics are not covered, and prior authorization is required for most services.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Jefferson Health Plans Silver (HMO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance, while chemotherapy and other Part B drugs require no copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Jefferson Health Plans Silver (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Jefferson Health Plans Silver (HMO) covers medical equipment with no copays, though prior authorization is required for durable medical equipment, prosthetics, medical supplies, and diabetic equipment. Covered items generally carry a 20% coinsurance, with the exception of diabetic supplies which range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Jefferson Health Plans Silver (HMO) covers diagnostic procedures and tests with no copay and no coinsurance, though lab services are not covered. Outpatient x-rays require a $25 copay, diagnostic radiological services have a minimum $200 copay, and therapeutic radiological services carry a minimum 20% coinsurance, with prior authorization required for most services.
Home Health Services See details
Jefferson Health Plans Silver (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Jefferson Health Plans Silver (HMO) covers Cardiac Rehabilitation Services with no copay and no coinsurance, but only some services are covered because standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Jefferson Health Plans Silver (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $195 daily copay for days 21 through 100. Prior authorization is required, no prior three-day hospital stay is needed, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Jefferson Health Plans Silver (HMO) provides partial coverage for other services, featuring acupuncture with a $10 copay and no coinsurance for up to 20 treatments annually, and over-the-counter (OTC) items with no copay and no coinsurance up to $125 every three months. Meal benefits and Naloxone are not covered.
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