A non-government entity
Jefferson Health Plans Giveback (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Giveback (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 Giveback (HMO) in 2026, please refer to our full plan details page.
Jefferson Health Plans Giveback (HMO) is a HMO plan offered by Thomas Jefferson University available for enrollment in 2025 to people living in Southeastern 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 Giveback (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 Giveback (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 Giveback (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. Additionally, this plan comes with a Part B Premium reduction of $140.00. 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.
This plan has a $300.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $9250.00 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 Giveback (HMO) prescription drug benefit features an annual drug deductible of $300. For Tier 1 preferred generic drugs, you will pay no copay for a one-month, two-month, or three-month supply at standard pharmacies and through standard mail order. Tier 2 generic drugs are available for a $10 copay for a one-month supply, while standard mail order offers a three-month supply for a $20 copay. For brand-name and specialty medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 20% coinsurance, and Tier 4 non-preferred drugs carry a 35% coinsurance. Tier 5 specialty drugs are covered at a 25% coinsurance for a one-month supply through standard pharmacies and mail order.
Additional Benefits
The Jefferson Health Plans Giveback (HMO) offers robust medical coverage featuring no copay for primary care visits, preventive services, and home health care. For inpatient hospital stays, members pay a $350 copay for days 1 through 5 and no copay for days 6 through 90, while specialist visits require a $40 copay. Emergency room visits carry a $100 copay and outpatient hospital services require a $400 copay, both with no coinsurance. This plan also includes valuable supplemental benefits, providing dental care with no copay up to a $2,250 annual limit and a $30 quarterly allowance for over-the-counter items with no copay. Routine vision and hearing exams are available for a $40 copay, with up to $200 annually for eyewear and coverage for prescription hearing aids. Additionally, specialized services like dialysis and durable medical equipment generally require a 20% coinsurance with no copay.
Inpatient Hospital See details
Inpatient hospital care is partially covered by Jefferson Health Plans Giveback (HMO) with no coinsurance, requiring a $350 copay for days 1 through 5 and no copay for days 6 through 90. Additional hospital days, upgrades, and non-Medicare-covered stays are not covered under this plan.
Outpatient Services See details
Jefferson Health Plans Giveback (HMO) covers outpatient services with no coinsurance, featuring a $400 copay for outpatient hospital and observation services, and a $350 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $40 copay with no coinsurance, while outpatient blood services are provided with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by the Jefferson Health Plans Giveback (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 Giveback (HMO), requiring a $250 copay for ground ambulance services and a 20% coinsurance for air ambulance services, with prior authorization required. While some transportation services are covered, transportation to plan-approved health-related locations and any other health-related locations is not covered.
Emergency Services See details
Jefferson Health Plans Giveback (HMO) covers emergency services with a $100 copay and no coinsurance, and urgently needed services with a $15 copay and no coinsurance, with both copays waived if you are admitted to the hospital within 24 hours. Worldwide emergency and urgent care are partially covered with no copay or coinsurance up to a $50,000 maximum benefit, though worldwide emergency transportation is not covered.
Primary Care See details
Jefferson Health Plans Giveback (HMO) features primary care physician visits with no copay and no coinsurance, while specialist, physical therapy, and mental health services carry a $40 copay and no coinsurance. Occupational therapy is covered with a $35 copay and no coinsurance, and chiropractic services are partially covered with a $15 copay and no coinsurance, as routine chiropractic care is not covered.
Preventive Services See details
Preventive services are partially covered by Jefferson Health Plans Giveback (HMO) with no copay and no coinsurance for covered benefits like annual physical exams and kidney disease education. However, many supplemental services are not covered, including health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, weight management, and therapeutic massage.
Hearing Services See details
Jefferson Health Plans Giveback (HMO) covers hearing services with no coinsurance, offering one routine hearing exam annually for a $40 copay and prescription hearing aids every two years with a copay between $500 and $1,975. This benefit is partially covered, as fitting and evaluations, OTC hearing aids, and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Jefferson Health Plans Giveback (HMO) provides partially covered vision services with no deductibles, including one routine eye exam per year for a $40 copay and no coinsurance. Eyewear is also partially covered with no copay or coinsurance, offering up to $200 annually for eyeglasses (lenses and frames) and unlimited contact lenses, while other eye exams, individual eyeglass lenses, individual frames, and upgrades are not covered.
Dental Services See details
Jefferson Health Plans Giveback (HMO) partially covers dental services, providing Medicare-covered dental care for a $40 copay and no coinsurance, and other covered preventive and comprehensive services with no copay and no coinsurance up to a $2,250 annual limit. However, fluoride treatments, adjunctive general services, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by the Jefferson Health Plans Giveback (HMO) with no copay and no coinsurance, though prior authorization is required. Covered Medicare Part B chemotherapy and other drugs have no copay and 0% to 20% coinsurance, while Part B insulin drugs require a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by the Jefferson Health Plans Giveback (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Jefferson Health Plans Giveback (HMO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic equipment, with no copay and required prior authorization. Under this plan, you will pay a 20% coinsurance for most items, though diabetic supplies range from no coinsurance to a 20% coinsurance.
Diagnostic and Radiological Services See details
Jefferson Health Plans Giveback (HMO) partially covers diagnostic services, offering diagnostic procedures and tests for a $20 copay and no coinsurance, while lab services are not covered. Covered radiological services require prior authorization and include a $300 copay and no coinsurance for diagnostic radiological services, a $40 copay and coinsurance for outpatient X-rays, and both a copay and a minimum 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Jefferson Health Plans Giveback (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Jefferson Health Plans Giveback (HMO) indicates some services are covered for cardiac rehabilitation with no copay and no coinsurance, but cardiac rehabilitation services, intensive cardiac rehabilitation services, pulmonary rehabilitation services, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Jefferson Health Plans Giveback (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior three-day hospital stay requirement, though prior authorization is required. You will pay no copay for days 1 to 20 and a $165 daily copay for days 21 to 100, while additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Jefferson Health Plans Giveback (HMO) partially covers other services, excluding meal benefits but covering acupuncture with a $10.00 copay and no coinsurance for up to 10 treatments per year. Over-the-counter (OTC) items are also covered with no copay and no coinsurance, providing up to a $30.00 allowance every three months.
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