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Jefferson Health Plans Dual Pearl (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Dual Pearl (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Jefferson Health Plans Dual Pearl (HMO D-SNP) in 2026, please refer to our full plan details page.
Jefferson Health Plans Dual Pearl (HMO D-SNP) is a HMO D-SNP 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 Dual Pearl (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Jefferson Health Plans Dual Pearl (HMO D-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Jefferson Health Plans Dual Pearl (HMO D-SNP).
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 Dual Pearl (HMO D-SNP), 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 a $615.00 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 Dual Pearl (HMO D-SNP) has an annual drug deductible of $615. Beneficiaries enjoy no copay for Tier 1 preferred generic drugs and Tier 6 select care drugs filled at standard pharmacies or through standard mail order. This coverage provides excellent value for those seeking to minimize out-of-pocket costs on essential maintenance medications. For other prescription tiers, costs are based on coinsurance at standard pharmacies and standard mail order. You will pay a 20% coinsurance for Tier 2 generic drugs, 24% coinsurance for Tier 3 preferred brand drugs, and 28% coinsurance for Tier 4 non-preferred drugs. Tier 5 specialty drugs carry a 25% coinsurance for a one-month supply.
Additional Benefits
The Jefferson Health Plans Dual Pearl (HMO D-SNP) provides robust medical coverage, featuring inpatient hospital stays with fixed copays of $1,350 for acute care and $2,080 for psychiatric care, with no coinsurance. Most outpatient services, primary care visits, specialist consultations, and emergency care require no copay, instead utilizing coinsurance rates between 20% and 30%. Additionally, skilled nursing facility stays require no copay for the first 20 days, followed by a $218 daily copay up to day 100. For everyday wellness, this plan covers routine dental services, home health care, and up to 25 annual one-way transportation trips with no copay and no coinsurance. Routine vision and hearing exams are available with no copay and a 30% coinsurance, which includes allowances for prescription hearing aids and up to $200 annually for eyewear. Members also receive extra perks with no copay or coinsurance, including a $200 quarterly over-the-counter allowance, homebound meals, and acupuncture visits.
Inpatient Hospital See details
Jefferson Health Plans Dual Pearl (HMO D-SNP) covers inpatient hospital services with no coinsurance, although prior authorization is required. Covered services include acute inpatient stays with a $1,350 copay per stay and psychiatric stays with a $2,080 copay per stay, while additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Jefferson Health Plans Dual Pearl (HMO D-SNP) covers outpatient services—including outpatient hospital, ambulatory surgical center, substance abuse, and blood services—with no copay and a 30% coinsurance. Prior authorization is required for ambulatory surgical center and outpatient hospital services.
Partial Hospitalization See details
Partial hospitalization is covered under the Jefferson Health Plans Dual Pearl (HMO D-SNP) with no copay and a 30% coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Jefferson Health Plans Dual Pearl (HMO D-SNP) covers ambulance services with a 30% coinsurance and no copay for ground and air transport, subject to prior authorization. Transportation services are partially covered with no copay or coinsurance for up to 25 yearly one-way trips to plan-approved locations, but trips to any health-related location are not covered.
Emergency Services See details
Jefferson Health Plans Dual Pearl (HMO D-SNP) covers emergency and urgent care services with a 30% coinsurance and no copay, with the emergency coinsurance waived if admitted to the hospital within 24 hours. Worldwide emergency and urgent services are also covered with no copay and no coinsurance up to a $50,000 limit, though worldwide emergency transportation is not covered.
Primary Care See details
Jefferson Health Plans Dual Pearl (HMO D-SNP) covers primary care, specialist, and other healthcare professional services with no copay and a 20% coinsurance, while chiropractic services are not covered. Other benefits, such as occupational therapy, physical therapy, mental health, psychiatric, telehealth, podiatry, and opioid treatment, are covered with no copay and a 30% coinsurance.
Preventive Services See details
Preventive services are covered by Jefferson Health Plans Dual Pearl (HMO D-SNP) with no copays, though a 20% coinsurance applies to annual physical exams and a 30% coinsurance applies to kidney disease education, glaucoma screenings, diabetes self-management, digital rectal exams, and post-welcome-visit EKGs. Additional preventive services are partially covered with no copay and no coinsurance for memory fitness and telemonitoring, but health education, in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, smoking cessation counseling, enhanced disease management, remote access technologies, home safety modifications, and counseling are not covered.
Hearing Services See details
Jefferson Health Plans Dual Pearl (HMO D-SNP) covers hearing services, offering one routine hearing exam annually with no copay and 30% coinsurance, and one prescription hearing aid per year with no coinsurance and a copay ranging from $0 to $1,475. Hearing aid fittings and evaluations, OTC hearing aids, and inner-ear, outer-ear, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Jefferson Health Plans Dual Pearl (HMO D-SNP) partially covers vision services, offering one routine eye exam per year with no copay and a 30% coinsurance, while other eye exam services are not covered. Eyewear is also partially covered with no copay and no coinsurance, covering unlimited contact lenses or one pair of eyeglasses up to a $200 annual limit, but separate eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by Jefferson Health Plans Dual Pearl (HMO D-SNP) with no copay and no coinsurance for covered preventive and comprehensive care. While services like cleanings, exams, and implants are covered, fluoride treatment, adjunctive general services, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Jefferson Health Plans Dual Pearl (HMO D-SNP) with no copay, while associated Part B chemotherapy and other drugs require no copay and a coinsurance ranging from no coinsurance to 20% coinsurance. Part B insulin is covered with a $35 copay and a coinsurance ranging from no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Jefferson Health Plans Dual Pearl (HMO D-SNP) with no copayment and a 20% coinsurance.
Medical Equipment See details
Jefferson Health Plans Dual Pearl (HMO D-SNP) medical equipment benefits, including durable medical equipment (DME), prosthetics, and diabetic supplies, are covered with no copay and a 20% coinsurance. Prior authorization is required for these services, and selection may be limited to preferred manufacturers or vendors.
Diagnostic and Radiological Services See details
Jefferson Health Plans Dual Pearl (HMO D-SNP) covers diagnostic and radiological services with no copay, though prior authorization is required. Diagnostic procedures, lab services, diagnostic radiology, and outpatient X-rays require a minimum 30% coinsurance, while therapeutic radiological services carry a minimum 20% coinsurance.
Home Health Services See details
Jefferson Health Plans Dual Pearl (HMO D-SNP) covers Home Health Services with no copay and no coinsurance. Prior authorization is required to receive these services.
Cardiac Rehabilitation Services See details
Jefferson Health Plans Dual Pearl (HMO D-SNP) covers some cardiac rehabilitation services with no copay, but standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) rehabilitation services are not covered and require a 30% coinsurance.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by Jefferson Health Plans Dual Pearl (HMO D-SNP) with no coinsurance, though prior authorization and a three-day prior inpatient hospital stay are required. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, with no coverage provided for additional days beyond the Medicare-covered limit.
Other Services See details
Other Services are partially covered by Jefferson Health Plans Dual Pearl (HMO D-SNP) with no copay and no coinsurance, including up to 20 acupuncture treatments annually, homebound meal benefits, and a $200 quarterly over-the-counter allowance. However, Naloxone is not covered under the over-the-counter benefit, and highly integrated services for dual eligibles are excluded.
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