Clover Health Choice (PPO)

by Clover Health

2027 Medicare Advantage plan available in New Jersey

Plan ID H5141-004-0

Additional coverage:

RxHearingVisionDental

Medicare Advantage PPO $0 premium

Monthly plan premium $0 / mo

Annual deductible $0 / yr

Max out-of-pocket · in-network $9,850 / yr

Drug deductible $350 / yr

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Plan Overview

Clover Health Choice (PPO) is a Medicare Advantage Plan With Part D Prescription Drug Coverage, which is available in New Jersey and offered by the health insurance company Clover Health. This plan's network type is PPO, which determines the in-network doctors who accept the plan and whether a referral is needed.

Plan Name Clover Health Choice (PPO)

Insurance Carrier Clover Health

Plan Type Medicare Advantage Plan With Part D Prescription Drug Coverage

Network Type PPO

Cost Summary

Clover Health Choice (PPO) has a monthly premium cost of $0 per month, with an annual deductible of $0 and a maximum out-of-pocket cost sharing of $9,850. The most common costs people evaluate when choosing a plan are listed here; a full list of benefit costs is defined below.

Monthly Premium $0 / mo

Health portion of premium $0

Drug portion of premium $0

Annual Deductible $0 / yr

Max Out-of-Pocket · in-network $9,850 / yr

Primary doctor visit $0 copay

Specialist visit $15 copay

ER visit $115 copay

Ambulance $325 copay

Additional Benefits and Coverage

Clover Health Choice (PPO) is a Medicare Advantage plan which includes Medicare Part D prescription drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. Clover Health Choice (PPO) includes coverage for hearing, vision, dental.

Part D Prescription Drug Coverage Yes

Dental Yes

Vision Yes

Hearing Yes

Nationwide Coverage No

Other benefits

Fitness benefit Limited coverage

Over-the-counter drug benefits Limited coverage

In-home support services Not covered

Home & bathroom safety devices Not covered

Meals for short duration Not covered

Annual physical exams Limited coverage

Telehealth Limited coverage

Medical Benefits

Doctor Services

Primary doctor visit In-network: $0 copay
Out-of-network: $0 copay

Specialist visit In-network: $15 copay
Out-of-network: $30 copay

Tests, labs & imaging

Diagnostic tests & procedures In-network: $0-$225 copay
Out-of-network: $0-$325 copay

Lab services In-network: $0-$25 copay
Out-of-network: $50 copay

Diagnostic radiology services (like MRI) In-network: $55-$225 copay
Out-of-network: $80-$325 copay

Outpatient x-rays In-network: $35 copay
Out-of-network: $55 copay

Emergency care $115 copay

Urgent care $35 copay

Hospital Services

Inpatient hospital coverage In-network:
  Tier 1
  $408 per day for days 1-6
  $0 per day for days 7-90
  $0 per stay
Out-of-network:
  $560 per day for days 1-6
  $0 per day for days 7-90
  $0 per stay

Outpatient hospital coverage In-network: $0-$408 copay
Out-of-network: $0-$560 copay

Skilled nursing facility

Skilled nursing facility In-network:
  Tier 1
  $0 per day for days 1-20
  $221 per day for days 21-100
Out-of-network:
  40% per stay

Preventive services

Preventive services In-network: $0 copay
Out-of-network: $0 copay

Ambulance

Ground ambulance In-network: $325 copay
Out-of-network: $325 copay

Therapy services

Occupational therapy visit In-network: $20 copay
Out-of-network: $30 copay

Physical therapy & speech & language therapy visit In-network: $20 copay
Out-of-network: $30 copay

Mental health services

Outpatient group therapy with a psychiatrist In-network: $30 copay
Out-of-network: $50 copay

Outpatient individual therapy with a psychiatrist In-network: $40 copay
Out-of-network: $60 copay

Outpatient group therapy visit In-network: $30 copay
Out-of-network: $50 copay

Outpatient individual therapy visit In-network: $40 copay
Out-of-network: $60 copay

Opioid treatment services

Opioid treatment services Covered

Other services

Durable medical equipment (like wheelchairs & oxygen) In-network: 20% coinsurance
Out-of-network: 25% coinsurance

Prosthetics (like braces, artificial limbs) In-network: 20% coinsurance
Out-of-network: 25% coinsurance

Diabetes supplies In-network: $0 copay
Out-of-network: $0 copay

Prescription drugs (Part D benefits)

Drug tier standard retail · 1-month supply Initial coverage Catastrophic

Preferred Generic $0.00 copay $0 copay

Generic $10.00 copay $0 copay

Preferred Brand $47.00 copay $0 copay

Non-Preferred Drug 31% coinsurance $0 copay

Specialty Tier 29% coinsurance $0 copay

Part B drugs

Chemotherapy drugs In-network: 0%-20% coinsurance
Out-of-network: 50% coinsurance

Other Part B drugs In-network: 0%-20% coinsurance
Out-of-network: 50% coinsurance

Extra Benefits

Hearing

Hearing exam In-network: $0 copay
Out-of-network: $0 copay

Fitting/evaluation In-network: $0 copay
Out-of-network: $0 copay

Hearing aids - prescription In-network: $499-$999 copay
Out-of-network: $5000 copay

Hearing aids - over the counter Not covered

Preventive dental

Oral exam In-network: $0 copay
Out-of-network: 50% coinsurance

Cleaning In-network: $0 copay
Out-of-network: 50% coinsurance

Fluoride treatment In-network: $0 copay
Out-of-network: 50% coinsurance

Dental x-rays In-network: $0 copay
Out-of-network: 50% coinsurance

Comprehensive dental

Restorative services In-network: $20 copay
Out-of-network: 50% coinsurance

Endodontics In-network: $20 copay
Out-of-network: 50% coinsurance

Periodontics In-network: $20 copay
Out-of-network: 50% coinsurance

Prosthodontics, removable In-network: 50% coinsurance
Out-of-network: 50% coinsurance

Prosthodontics, fixed In-network: $20 copay
Out-of-network: 50% coinsurance

Maxillofacial prosthetics In-network: $20 copay
Out-of-network: 50% coinsurance

Implant services In-network: $20 copay
Out-of-network: 50% coinsurance

Oral and maxillofacial surgery In-network: $20 copay
Out-of-network: 50% coinsurance

Orthodontics Not covered

Adjunctive general services In-network: $20 copay
Out-of-network: 50% coinsurance

Vision

Routine eye exam In-network: $0 copay
Out-of-network: $0 copay

Contact lenses In-network: $0 copay
Out-of-network: $0 copay

Eyeglasses (frames & lenses) In-network: $0 copay
Out-of-network: $0 copay

Eyeglass frames (only) Not covered

Eyeglass lenses (only) Not covered

Upgrades Not covered

Plan documents & tools

Plan details (carrier site)Provider directory Drug list (formulary)

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