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Clover Health

Plan ID: H5141-57-0

Clover Health Valor (PPO)

2024 Clover Health Valor (PPO) H5141 — 057— 0 is a Medicare Advantage plan . It has received a 3-out-of-5 star rating from CMS for 2024.

Learn more about Clover Health Valor (PPO) H5141 - 057 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

3 / 5 stars for 2024

$0 /mo

Monthly premium

Health deductible

$7499.00

Out-of-pocket maximum

Enroll online

Call to enroll

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1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week!

Overview Benefits & Costs Drug Coverage Additional Benefits

Plan Overview

2024 Clover Health Valor (PPO) H5141 — 057— 0 is a Local PPO offered in Select South Carolina Counties by Clover Health. It has a monthly premium of $0.00 and includes a Part B premium discount of $100.00.

Premium Breakdown

Standard Part B Premium

$174.80

Part B premium reduction

$100.00

Part C Premium

Monthly Premium (Parts C & D)

$0.00

Total Premium (Parts B, C, & D)

$64.90

Special needs plan type

Out-of-pocket maximum

$7499.00

Plan Organization:

Clover Health

Plan Type:

Local PPO

Location:

Select South Carolina Counties

Drugs Covered:

Drug Formulary:

Formulary Link

Pharmacies:

Pharmacies Link

Doctor Choice:

Any Doctor

Doctors Link:

Doctors Link

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Health deductible

Sign up for Clover Health Valor (PPO)

Enroll online

Call to enroll

Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week

Drug Coverage

Clover Health Valor (PPO) does not provide drug coverage. If drug coverage is something you need, you should consider shopping for other plans that do provide cost sharing on drugs.

Additional Benefits

Clover Health Valor (PPO) also provides the following benefits.

Comprehensive dental

Non-routine services

Not covered

Diagnostic services

Not covered

Restorative services

In-Network: $20 copay

Out-Of-Network: $20 copay

Endodontics

In-Network: $20 copay

Out-Of-Network: $20 copay

Periodontics

In-Network: $20 copay

Out-Of-Network: $20 copay

Extractions

In-Network: $20 copay

Out-Of-Network: $20 copay

Prosthodontics, other oral/maxillofacial surgery, other services

In-Network: $20 copay

Out-Of-Network: $20 copay

Preventive dental

Oral exam

In-Network: $0 copay

Out-Of-Network: $0 copay

Cleaning

In-Network: $0 copay

Out-Of-Network: $0 copay

Fluoride treatment

In-Network: $0 copay

Out-Of-Network: $0 copay

Dental x-ray(s)

In-Network: $0 copay

Out-Of-Network: $0 copay

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures

In-Network: $0-250 copay

Out-Of-Network: 0-30% coinsurance

Lab services

In-Network: $0-20 copay

Out-Of-Network: $0-40 copay

Diagnostic radiology services (eg, MRI)

In-Network: $0-250 copay

Out-Of-Network: 30% coinsurance

Outpatient x-rays

In-Network: $40 copay

Out-Of-Network: 30% coinsurance

Doctor visits

Primary

In-Network: $15 copay per visit

Out-Of-Network: $30 copay per visit

Specialist

In-Network: $35 copay per visit

Out-Of-Network: $50 copay per visit

Emergency care/Urgent care

Emergency

$100 copay per visit (always covered)

Urgent care

$25 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment

In-Network: $35 copay

Out-Of-Network: 30% coinsurance

Routine foot care

Not covered

Ground ambulance

Service

In-Network: $350 copay

Out-Of-Network: $350 copay

Hearing

Hearing exam

In-Network: $35 copay

Out-Of-Network: 30% coinsurance

Fitting/evaluation

In-Network: $0 copay

Out-Of-Network: $0 copay

Hearing aids

In-Network: $699-999 copay

Out-Of-Network: $999 copay

Inpatient hospital coverage

Service

In-Network: $360 per day for days 1 through 6 $0 per day for days 7 through 90

Out-Of-Network: $495 per day for days 1 through 6 $0 per day for days 7 through 90

Outpatient hospital coverage

Service

In-Network: 0-20% coinsurance per visit

Out-Of-Network: 0-30% coinsurance per visit

Outpatient prescription drugs

Clover Health Valor (PPO) does not provide this type of benefit.

Optional benefits

Clover Health Valor (PPO) does not provide this type of benefit.

Medical equipment/supplies

Durable medical equipment (eg, wheelchairs, oxygen)

In-Network: 20% coinsurance per item

Out-Of-Network: 20% coinsurance per item

Prosthetics (eg, braces, artificial limbs)

In-Network: 20% coinsurance per item

Out-Of-Network: 20% coinsurance per item

Diabetes supplies

In-Network: 20% coinsurance per item

Out-Of-Network: 30% coinsurance per item

Medicare Part B drugs

Chemotherapy

In-Network: 0-20% coinsurance

Out-Of-Network: 40% coinsurance

Other Part B drugs

In-Network: 0-20% coinsurance

Out-Of-Network: 40% coinsurance

Part B Insulin drugs

In-Network: $35 copay

Out-Of-Network: 40% coinsurance

Mental health services

Inpatient hospital - psychiatric

In-Network: $320 per day for days 1 through 6 $0 per day for days 7 through 90

Out-Of-Network: $495 per day for days 1 through 6 $0 per day for days 7 through 90

Outpatient group therapy visit with a psychiatrist

In-Network: $35 copay

Out-Of-Network: 30% coinsurance

Outpatient individual therapy visit with a psychiatrist

In-Network: $35 copay

Out-Of-Network: 30% coinsurance

Outpatient group therapy visit

In-Network: $35 copay

Out-Of-Network: 30% coinsurance

Outpatient individual therapy visit

In-Network: $35 copay

Out-Of-Network: 30% coinsurance

Preventive care

Service

In-Network: $0 copay

Out-Of-Network: 30% coinsurance

Rehabilitation services

Occupational therapy visit

In-Network: $35 copay

Out-Of-Network: 30% coinsurance

Physical therapy and speech and language therapy visit

In-Network: $35 copay

Out-Of-Network: 30% coinsurance

Skilled Nursing Facility

Service

In-Network: $0 per day for days 1 through 20 $203 per day for days 21 through 100

Out-Of-Network: 30% per stay

Transportation

Service

Not covered

Vision

Routine eye exam

In-Network: $0 copay

Out-Of-Network: $0 copay

Other

Not covered

Contact lenses

In-Network: $0 copay

Out-Of-Network: $0 copay

Eyeglasses (frames and lenses)

In-Network: $0 copay

Out-Of-Network: $0 copay

Eyeglass frames

Not covered

Eyeglass lenses

Not covered

Upgrades

Not covered

Wellness programs (eg, fitness, nursing hotline)

Service

Covered

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1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week

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