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Jefferson Health Plans Elite (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Elite (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 Elite (HMO) in 2026, please refer to our full plan details page.
Jefferson Health Plans Elite (HMO) is a HMO plan offered by Thomas Jefferson University available for enrollment in 2026 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 Elite (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 Elite (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 Elite (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 $6000.00 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 Elite (HMO) features a $0 drug deductible, meaning you do not have to pay an upfront deductible before your prescription drug coverage begins. For Tier 1 (Preferred Generic) and Tier 2 (Generic) drugs, there is no copay for one-month, two-month, or three-month supplies filled at standard pharmacies or through standard mail order. For brand-name and specialty medications, costs are based on coinsurance rather than set copays. Tier 3 (Preferred Brand) drugs require a 25% coinsurance, Tier 4 (Non-Preferred) drugs require a 34% coinsurance, and Tier 5 (Specialty) drugs require a 33% coinsurance for a one-month supply at standard pharmacies and standard mail order.
Additional Benefits
Jefferson Health Plans Elite (HMO) offers robust medical coverage featuring no copay for primary care visits, specialist consultations, and routine preventive services. Inpatient hospital stays require a copayment ranging from $450 to $800 per stay with no coinsurance, while outpatient hospital services carry a $300 copay. Emergency room visits have a $100 copay, which is waived if you are admitted to the hospital within 24 hours. For extra wellness needs, the plan includes dental care up to a $5,000 annual maximum and a $200 yearly allowance for eyewear with no copay. Routine hearing exams are covered with a $35 copay, and members can access prescription hearing aids with copayments between $500 and $1,975. Additionally, members receive a $125 allowance every three months for over-the-counter items with no copay.
Inpatient Hospital See details
Jefferson Health Plans Elite (HMO) partially covers inpatient acute and psychiatric hospital services with no coinsurance and copayments ranging from $450 to $800 per stay, with prior authorization required. Upgrades, additional days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Jefferson Health Plans Elite (HMO) covers outpatient hospital and observation services for a $300 copay with no coinsurance, and ambulatory surgical center services for a $200 copay with no coinsurance. Outpatient blood services have no copay or coinsurance, and although some outpatient substance abuse services are covered, individual and group sessions are not covered.
Partial Hospitalization See details
Jefferson Health Plans Elite (HMO) covers partial hospitalization benefits with a $55 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Jefferson Health Plans Elite (HMO) covers ambulance services with prior authorization, requiring a $210 copay and no coinsurance for ground transport, and a 20% coinsurance and no copay for air transport. For transportation, some services are covered, but transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
Jefferson Health Plans Elite (HMO) covers emergency services with a $100 copay and no coinsurance, and urgently needed services with a $10 copay and no coinsurance, both waived if admitted to the hospital within 24 hours. Worldwide emergency and urgent services are partially covered up to a $50,000 lifetime maximum with no copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Jefferson Health Plans Elite (HMO) offers primary care, specialist visits, podiatry, and telehealth services with no copay and no coinsurance, while physical, occupational, speech, and opioid treatment services require a $25 copay and no coinsurance. However, routine chiropractic care, as well as individual and group sessions for mental health and psychiatric services, are not covered.
Preventive Services See details
Jefferson Health Plans Elite (HMO) covers preventive services, such as annual physical exams and kidney disease education, with no copay and no coinsurance. Additional preventive services are partially covered, excluding health education, personal emergency response systems, in-home safety assessments, medical nutrition therapy, weight management, and adult day health. Covered additional services, including memory fitness and telemonitoring, also require no copay and no coinsurance.
Hearing Services See details
Hearing services are partially covered by Jefferson Health Plans Elite (HMO), which features one annual routine hearing exam for a $35 copay and no coinsurance, with no deductible. Prescription hearing aids are covered once every two years with a copay ranging from $500.00 to $1,975.00 and no coinsurance, but fitting and evaluation, OTC hearing aids, and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision Services are partially covered by Jefferson Health Plans Elite (HMO) with no deductibles, offering one routine eye exam per year for a $40 copay and no coinsurance, and eyewear with no copay and no coinsurance up to a $200 annual limit for eyeglasses (lenses and frames) or contact lenses. Other eye exam services, individual eyeglass lenses, individual eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by Jefferson Health Plans Elite (HMO) up to a $5,000 annual maximum, requiring a $40 copay and no coinsurance for Medicare-covered services, and no copay or coinsurance for other covered services. Fluoride treatment, adjunctive general services, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Jefferson Health Plans Elite (HMO) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy and other Part B drugs require no copay and a coinsurance ranging from no coinsurance to 20%, while Part B insulin is covered with a $35 copay and up to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Jefferson Health Plans Elite (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Jefferson Health Plans Elite (HMO) covers durable medical equipment, prosthetics, medical supplies, and diabetic equipment with no copays, though prior authorization is required. A 20% coinsurance applies to most of these items, including prosthetic devices and therapeutic shoes, while diabetic supplies range from no coinsurance up to 20% coinsurance.
Diagnostic and Radiological Services See details
Jefferson Health Plans Elite (HMO) partially covers diagnostic and radiological services, offering diagnostic procedures and tests with no copay and no coinsurance, though lab services are not covered. Covered radiological services require prior authorization and include outpatient X-rays for a $25 copay, diagnostic radiological services for a $200 copay, and therapeutic radiological services with a 20% coinsurance.
Home Health Services See details
Jefferson Health Plans Elite (HMO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Jefferson Health Plans Elite (HMO) does not cover Cardiac Rehabilitation Services, as standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
Jefferson Health Plans Elite (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $185 daily copay for days 21 through 100. Prior authorization is required, a prior three-day inpatient hospital stay is not necessary, and additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
Other Services are partially covered under Jefferson Health Plans Elite (HMO), which includes acupuncture for a $10 copay and no coinsurance up to 20 treatments per year, and over-the-counter items with no copay and no coinsurance up to $125 every three months, while meal benefits are not covered.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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