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Jefferson Health Plans offers a wide range of health insurance products to residents of the Philadelphia area. Senior Medicare and private individual and family medical coverage is available. Jefferson Health is rated as a top-15 US academic health system (non-profit). PPO, HMO, and HMO-DSNP options. More than 65,000 employees, 4,000 physicians, 13,000 nurses, and 1,800 faculty members work together to treat patients. Coverage is offered in Philadelphia, Bucks, Montgomery, Adams, Cumberland, York, Lancaster, Chester, Delaware, and Franklin Counties.
Group employer coverage is also offered that customizes benefits and includes cost-saving features to keep premiums affordable. Included in most plans is health coverage, dental coverage, prescription drug coverage, accidental death and life insurance, and an Employee Assistance Program (EAP). EAP resources include financial stability, recovery, healthy living, managing life events, and achieving personal and family goals.
Jefferson Health Plans Individual And Family (Under Age 65)
Catastrophic Tier
No Available Plans
Bronze Tier
Value + Bronze + HMO + On Exchange – $8,500 deductible with maximum out-of-pocket expenses of $9,200. Coinsurance is 0%. No charge for children’s eye exam. One refraction visit is allowed. No charge for children’s glasses. Three pairs of contacts or glasses each calendar year.
Total + Bronze + HMO + On Exchange – $7,900 deductible with maximum out-of-pocket expenses of $9,200. Coinsurance is 50%. Office visit copays are $60 (pcp) and $95 (specialist) for Tier 1 visits and $95 and $150 for Tier 2 visits. Diagnostic test (blood work and x-rays) and imaging (MRIs and CT/PET scans) copays are $175/$75 and $300 for Tier 1 visits and $250/$150 and $350 for Tier 2 visits. Generic and preferred brand drug copays are $35 and $150. Non-preferred brand drugs are subject to deductible. ER visits are subject to the deductible and the Urgent Care copay is $95 (Tier 1) and $150 (Tier 2). Physical, occupational, and speech therapy visits subject to copays of $135 (Tier 1) and $150 (tier 2).
$0 Deductible + Bronze + HMO + On Exchange – $0 deductible with maximum out-of-pocket expenses of $5,000. Coinsurance is 50%. Office visit copays are $95 (pcp) and $150 (specialist) for Tier 1 visits and $150 and $175 for Tier 2 visits. Diagnostic test (blood work and x-rays) and imaging (MRIs and CT/PET scans) copays are $200/$150 and $600 for Tier 1 visits and $350/$250 and $750 for Tier 2 visits. Generic and preferred brand drug copays are $35 and $150. Non-preferred brand drugs are subject to deductible. ER visits are subject to a $1,200 copay (Tier 2 must also pay deductible) and the Urgent Care copay is $150 (Tier 1) and $175 (Tier 2). Physical, occupational, and speech therapy visits subject to copays of $150 (Tier 1) and $250 (tier 2).
Silver Tier
Total + Silver + HMO + On Exchange – $4,900 deductible with maximum out-of-pocket expenses of $9,200. Coinsurance is 20% (Tier 1) and 30% (Tier 2). Office visit copays are $40 (pcp) and $85 (specialist) for Tier 1 visits and $85 and $125 for Tier 2 visits. Diagnostic test (blood work and x-rays) and imaging (MRIs and CT/PET scans) copays are $150/$50 and $300 for Tier 1 visits and $300/$100 and $450 for Tier 2 visits. Generic and preferred brand drug copays are $20 and 50%. Non-preferred brand drugs are subject to deductible. ER visits are subject to a $950 copay and the Urgent Care copay is $85 (Tier 1) and $125 (Tier 2). Physical, occupational, and speech therapy visits subject to copays of $100.
Balanced + Silver + HMO + On Exchange – $2,400 deductible with maximum out-of-pocket expenses of $9,200. Coinsurance is 30% (Tier 1) and 40% (Tier 2). Office visit copays are $45 (pcp) and $90 (specialist) for Tier 1 visits and $90 and $130 for Tier 2 visits. Diagnostic test (blood work and x-rays) and imaging (MRIs and CT/PET scans) copays are $150/$50 and $300 for Tier 1 visits and $300/$100 and $450 for Tier 2 visits. Generic and preferred brand drug copays are $20 and 50%. Non-preferred brand drugs are subject to deductible. ER visits are subject to a $950 copay and the Urgent Care copay is $90 (Tier 1) and $130 (Tier 2). Physical, occupational, and speech therapy visits subject to copays of $100. Skilled nursing care copay of $550 for maximum 5 days (Tier 1) and $850 for maximum 5 days (Tier 2).
$0 Deductible + Silver + HMO + On Exchange – $0 deductible with maximum out-of-pocket expenses of $9,200. Coinsurance is 20% (Tier 1) and 40% (Tier 2). Office visit copays are $50 (pcp) and $95 (specialist) for Tier 1 visits and $95 and $130 for Tier 2 visits. Diagnostic test (blood work and x-rays) and imaging (MRIs and CT/PET scans) copays are $175/$60 and $350 for Tier 1 visits and $300/$100 and $500 for Tier 2 visits. Generic and preferred brand drug copays are $20 and $100. Non-preferred brand drugs are subject to deductible. ER visits are subject to a $975 copay and the Urgent Care copay is $95 (Tier 1) and $130 (Tier 2). Physical, occupational, and speech therapy visits subject to copays of $100 (Tier 1) and $130 (Tier 2). Skilled nursing care copay of $595 for maximum 5 days (Tier 1) and $1,000 for maximum 5 days (Tier 2).
Gold Tier
Value + Gold + HMO + On Exchange – $1,500 deductible with maximum out-of-pocket expenses of $9,200. Coinsurance is 50% (Tier 1) and 50% (Tier 2). Office visit copays are $15 (pcp) and $60 (specialist) for Tier 1 visits and $60 and $100 for Tier 2 visits. Diagnostic test (blood work and x-rays) and imaging (MRIs and CT/PET scans) copays are $50/$0 and $100 for Tier 1 visits and $80/$50 and $150 for Tier 2 visits. Generic and preferred brand drug copays are $20 and $100. Non-preferred brand drugs are subject to deductible. ER visits are subject to a $300 copay and the Urgent Care copay is $60 (Tier 1) and $100 (Tier 2). Physical, occupational, and speech therapy visits subject to copays of $60 (Tier 1) and $100 (Tier 2). Skilled nursing care copay of $250 for maximum 5 days (Tier 1) and $500 for maximum 5 days (Tier 2).
Total + Gold + HMO + On Exchange – $500 deductible with maximum out-of-pocket expenses of $9,200. Coinsurance is 50% (Tier 1) and 50% (Tier 2). Office visit copays are $0 (pcp) and $110 (specialist) for Tier 1 visits and $60 and $100 for Tier 2 visits. Diagnostic test (blood work and x-rays) and imaging (MRIs and CT/PET scans) copays are $60/$0 and $110 for Tier 1 visits and $80/20% and $150 for Tier 2 visits. Generic and preferred brand drug copays are $20 and $100. Non-preferred brand drugs are subject to deductible. ER visits are subject to a $400 copay and the Urgent Care copay is $65 (Tier 1) and $100 (Tier 2). Physical, occupational, and speech therapy visits subject to copays of $65 (Tier 1) and $100 (Tier 2). Skilled nursing care copay of $300 for maximum 5 days (Tier 1) and $500 for maximum 5 days (Tier 2).
$0 Deductible + Gold + HMO + On Exchange – $0 deductible with maximum out-of-pocket expenses of $9,200. Coinsurance is 50% (Tier 1) and 50% (Tier 2). Office visit copays are $25 (pcp) and $75 (specialist) for Tier 1 visits and $75 and $100 for Tier 2 visits. Diagnostic test (blood work and x-rays) and imaging (MRIs and CT/PET scans) copays are $80/$5 and $120 for Tier 1 visits and $120/$65 and $150 for Tier 2 visits. Generic and preferred brand drug copays are $20 and $100. Non-preferred brand drugs are subject to deductible. ER visits are subject to a $450 copay and the Urgent Care copay is $75 (Tier 1) and $100 (Tier 2). Physical, occupational, and speech therapy visits subject to copays of $75 (Tier 1) and $100 (Tier 2). Skilled nursing care copay of $350 for maximum 5 days (Tier 1) and $550 for maximum 5 days (Tier 2).
For all plans…No charge for children’s eye exam. One refraction visit is allowed. No charge for children’s glasses. Three pairs of contacts or glasses each calendar year.
Current Under-65 Rates
Age 30 With $36,000 Household Income Residing In Philadelphia, Bucks, and Montgomery Counties
$6 – Value + Bronze
$16 – Total + Bronze
$21 – $0 Deductible + Bronze
$97 – Value + Gold
$105 – Total + Gold
$121 – Total + Silver
$122 – $0 + Gold
$133 – Balanced + Silver
$172 – $0 Deductible + Silver
Age 30 And One Child With $42,000 Household Income Residing In Philadelphia, Bucks, and Montgomery Counties (Child Eligible For CHIP)
$4 – Value + Bronze
$14 – Total + Bronze
$19 – $0 Deductible + Bronze
$95 – Value + Gold
$103 – Total + Gold
$119 – Total + Silver
$120 – $0 + Gold
$131 – Balanced + Silver
$170 – $0 Deductible + Silver
Age 35 With $40,000 Household Income Residing In Philadelphia, Bucks, and Montgomery Counties
$45 – Value + Bronze
$55 – Total + Bronze
$62 – $0 Deductible + Bronze
$143 – Value + Gold
$151 – Total + Gold
$169 – Total + Silver
$170 – $0 + Gold
$182 – Balanced + Silver
$224 – $0 Deductible + Silver
Age 40 With $42,000 Household Income Residing In Philadelphia, Bucks, and Montgomery Counties
$67 – Value + Bronze
$78 – Total + Bronze
$84 – $0 Deductible + Bronze
$97 – Value + Gold
$170 – Total + Gold
$178 – Total + Silver
$197 – $0 + Gold
$210 – Balanced + Silver
$254 – $0 Deductible + Silver
Married Couple Age 40 With $58,000 Household Income Residing In Philadelphia, Bucks, and Montgomery Counties
$31 – Value + Bronze
$53 – Total + Bronze
$66 – $0 Deductible + Bronze
$237 – Value + Gold
$253 – Total + Gold
$291 – Total + Silver
$292 – $0 + Gold
$317 – Balanced + Silver
$405 – $0 Deductible + Silver
Married Couple Age 40 And Two Children With $90,000 Household Income Residing In Philadelphia, Bucks, and Montgomery Counties
$236 – Value + Bronze
$271 – Total + Bronze
$292 – $0 Deductible + Bronze
$570 – Value + Gold
$597 – Total + Gold
$658 – Total + Silver
$659 – $0 + Gold
$700 – Balanced + Silver
$843 – $0 Deductible + Silver
Married Couple Age 50 And Two Children With $105,000 Household Income Residing In Philadelphia, Bucks, and Montgomery Counties
$145 – Value + Bronze
$189 – Total + Bronze
$215 – $0 Deductible + Bronze
$562 – Value + Gold
$595 – Total + Gold
$671 – Total + Silver
$672 – $0 + Gold
$723 – Balanced + Silver
$902 – $0 Deductible + Silver
Age 50 With $50,000 Household Income Residing In Philadelphia, Bucks, and Montgomery Counties
$124 – Value + Bronze
$140 – Total + Bronze
$149 – $0 Deductible + Bronze
$268 – Value + Gold
$280 – Total + Gold
$306 – Total + Silver
$306 – $0 + Gold
$324 – Balanced + Silver
$386 – $0 Deductible + Silver
Married Couple Age 60 With $65,000 Household Income Residing In Philadelphia, Bucks, and Montgomery Counties
$0 – Value + Bronze
$0 – Total + Bronze
$0 – $0 Deductible + Bronze
$304 – Value + Gold
$339 – Total + Gold
$419 – Total + Silver
$420 – $0 + Gold
$474 – Balanced + Silver
$661 – $0 Deductible + Silver
Age 60 With $50,000 Household Income Residing In Philadelphia, Bucks, and Montgomery Counties
$42 – Value + Bronze
$65 – Total + Bronze
$79 – $0 Deductible + Bronze
$261 – Value + Gold
$278 – Total + Gold
$318 – Total + Silver
$319 – $0 + Gold
$345 – Balanced + Silver
$439 – $0 Deductible + Silver
Jefferson Health Pans Medicare Advantage Options For Seniors
Complete (HMO) – $0 monthly premium and $0 deductible. $5,700 maximum out-of-pocket expenses. 3,541 formulary drugs are offered, and the formulary exception (if approved) is Tier 4. Available drugs per tier are 398 (Tier 1), 942 (Tier 2), 572 (Tier 3), 837 (Tier 4), and 792 (Tier 5). 2,602 members are enrolled in the state, and 2,665 countrywide. The Plan’s Summary Star Rating is 3.5 (4.0 Customer Service).
Doctor visit copays are $0 (primary care physician) and $25 (specialist). Diagnostic tests and procedures copay is $5, lab services copay is $0, diagnostic radiology services copay is $250, and outpatient x-rays copay is $25. The ER and Urgent Care copays are $100 and $10. The inpatient hospital copay is $250 per day for the first six days. The outpatient hospital copay is $300 per visit. Skilled nursing copays are $0 for the first 20 days and $203 for days 21-100.
The ground ambulance copay is $250 and occupational therapy visits have a $25 copay. Mental health services include: Psychiatric inpatient hospital $250 per day, $25 copay for outpatient group therapy visits, and $25 copay for outpatient individual therapy visits. Durable medical equipment is subject to 20% coinsurance. Hearing exams have a $35 copay and Medicare-covered dental services have a $45 copay. Routine eye exams also have a $45 copay. Contact lenses and eyeglasses have a $0 copay, subject to policy limits.
Chiropractic services have a $15 copay and some acupuncture is covered. Foot exams are subject to a $25 copay. Additional included benefits (subject to policy limitations) include: Transportation services, drug benefits (over the counter), annual physical exams, telehealth, worldwide emergency coverage, and fitness benefit.
30-Day Cost-Sharing Preferred Pharmacy prescription drug copays: $0 (Tier 1 Preferred Generic), $10 (Tier 2 Generic), 25% (Tier 3 Preferred Brand), 35% (Tier 4 Non-Preferred Drug), and 33% (Tier 5 Specialty). 90-Day Cost-Sharing Mail-Order prescription drug copays: $0 (Tier 1 Preferred Generic), $20 (Tier 2 Generic), 25% (Tier 3 Preferred Brand), 35% (Tier 4 Non-Preferred Drug), and n/a (Tier 5 Specialty).
Dual Pearl (HMO) – $0 monthly premium and $0 deductible. $8,850 maximum out-of-pocket expenses. 3,532 formulary drugs are offered. Available drugs per tier are not available. 292 members are enrolled in the state, and 330 countrywide. The Plan’s Summary Star Rating is 3.5 (4.0 Customer Service).
Doctor visit copays are $0 or 20% (primary care physician) and $0 or 20% (specialist). Diagnostic tests and procedures copay is $0 or 20%, lab services copay is $0 or 20%, diagnostic radiology services copay is $0 or 20%, and outpatient x-rays copay is $0 or 20%. The ER and Urgent Care copays are $0 or 20%. The inpatient hospital copay is $0. The outpatient hospital copay is $0 or 20%. Skilled nursing requires authorization.
The ground ambulance copay is $0 or 20% and occupational therapy visits have a $0 or 20% copay. Mental health services include: Psychiatric inpatient hospital, $0 or 20% copay for outpatient group therapy visits, and $0 or 20% copay for outpatient individual therapy visits. Durable medical equipment is subject to $0 or 20% coinsurance. Hearing exams have a $0 or 20% copay and Medicare-covered dental services have a $0 copay. Routine eye exams also have a $0 copay. Contact lenses and eyeglasses have a $0 copay, subject to policy limits.
Chiropractic services have a 20% copay and some acupuncture is covered. Foot exams are subject to a $0 or 20%copay. Additional included benefits (subject to policy limitations) include: Transportation services, drug benefits (over the counter), annual physical exams, telehealth, and fitness benefit.
30-Day Cost-Sharing Preferred Pharmacy prescription drug copays: $0 (Tier 1 Preferred Generic), $0 (Tier 2 Generic), $0 (Tier 3 Preferred Brand), $0 (Tier 4 Non-Preferred Drug), and $0 (Tier 5 Specialty). 90-Day Cost-Sharing Mail-Order prescription drug copays: $0 (Tier 1 Preferred Generic), $0 (Tier 2 Generic), $0 (Tier 3 Preferred Brand), $0 (Tier 4 Non-Preferred Drug), and $0 (Tier 5 Specialty).
Flex (PPO) – $0 monthly premium and $0 deductible. $7,000 maximum out-of-pocket expenses. 3,375 formulary drugs are offered, and the formulary exception (if approved) is Tier 4. Available drugs per tier are 332 (Tier 1), 601 (Tier 2), 806 (Tier 3), 867 (Tier 4), and 769 (Tier 5). 520 members are enrolled in the state, and 586 countrywide. The Plan’s Summary Star Rating is 4.0 (Customer Service).
Doctor visit copays are $0 (primary care physician) and $35 (specialist). Diagnostic tests and procedures copay is $0, lab services copay is $0, diagnostic radiology services copay is $250, and outpatient x-rays copay is $35. The inpatient hospital copay is $250 per day for the first six days. The outpatient hospital copay is $375 per visit. Skilled nursing copays are $0 for the first 20 days and $203 for days 21-100.
The ground ambulance copay is $255 and occupational therapy visits have a $35 copay. Mental health services include: Psychiatric inpatient hospital $250 per day, $25 copay for outpatient group therapy visits, and $35 copay for outpatient individual therapy visits. Durable medical equipment is subject to 20% coinsurance. Hearing exams have a $35 copay and Medicare-covered dental services have a $35 copay. Routine eye exams also have a $35 copay. Contact lenses and eyeglasses have a $0 copay, subject to policy limits.
Chiropractic services have a $15 copay and some acupuncture is covered. Foot exams are subject to a $35 copay. Additional included benefits (subject to policy limitations) include: Drug benefits (over the counter), annual physical exams, telehealth, worldwide emergency coverage, telemonitoring services, and fitness benefit.
30-Day Cost-Sharing Preferred Pharmacy prescription drug copays: $0 (Tier 1 Preferred Generic), $5 (Tier 2 Generic), 25% (Tier 3 Preferred Brand), 40% (Tier 4 Non-Preferred Drug), and 33% (Tier 5 Specialty). 90-Day Cost-Sharing Mail-Order prescription drug copays: $0 (Tier 1 Preferred Generic), $15 (Tier 2 Generic), 25% (Tier 3 Preferred Brand), 40% (Tier 4 Non-Preferred Drug), and n/a (Tier 5 Specialty).
Flex Plus (PPO) – $37 monthly premium and $0 deductible. $6,900 maximum out-of-pocket expenses. 3,375 formulary drugs are offered, and the formulary exception (if approved) is Tier 4. Available drugs per tier are 398 (Tier 1), 942 (Tier 2), 572 (Tier 3), 837 (Tier 4), and 792 (Tier 5). 795 members are enrolled in the state, and 839 countrywide. The Plan’s Summary Star Rating is 4.0 (Customer Service).
Doctor visit copays are $0 (primary care physician) and $20 (specialist). Diagnostic tests and procedures copay is $0, lab services copay is $0, diagnostic radiology services copay is $200, and outpatient x-rays copay is $35. The inpatient hospital copay is $425. The outpatient hospital copay is $250 per visit. Skilled nursing copays are $0 for the first 20 days and $203 for days 21-100.
The ground ambulance copay is $250 and occupational therapy visits have a $20 copay. Mental health services include: Psychiatric inpatient hospital $400 per day, $20 copay for outpatient group therapy visits, and $20 copay for outpatient individual therapy visits. Durable medical equipment is subject to 20% coinsurance. Hearing exams have a $35 copay and Medicare-covered dental services have a $20 copay. Routine eye exams also have a $20 copay. Contact lenses and eyeglasses have a $0 copay, subject to policy limits.
Chiropractic services have a $15 copay and some acupuncture is covered. Foot exams are subject to a $20 copay. Additional included benefits (subject to policy limitations) include: Drug benefits (over the counter), annual physical exams, telehealth, worldwide emergency coverage, telemonitoring services, and fitness benefit.
30-Day Cost-Sharing Preferred Pharmacy prescription drug copays: $0 (Tier 1 Preferred Generic), $5 (Tier 2 Generic), 25% (Tier 3 Preferred Brand), 35% (Tier 4 Non-Preferred Drug), and 33% (Tier 5 Specialty). 90-Day Cost-Sharing Mail-Order prescription drug copays: $0 (Tier 1 Preferred Generic), $15 (Tier 2 Generic), 25% (Tier 3 Preferred Brand), 35% (Tier 4 Non-Preferred Drug), and n/a (Tier 5 Specialty).
Flex Pro (PPO) – $20 monthly premium and $0 deductible. $6,000 maximum out-of-pocket expenses. 3,541 formulary drugs are offered, and the formulary exception (if approved) is Tier 4. Available drugs per tier are 398 (Tier 1), 942 (Tier 2), 572 (Tier 3), 837 (Tier 4), and 792 (Tier 5). 83 members are enrolled in the state, and 148 countrywide. The Plan’s Summary Star Rating is 4.0 (Customer Service).
Doctor visit copays are $0 (primary care physician) and $35 (specialist). Diagnostic tests and procedures copay is $0, lab services copay is $0, diagnostic radiology services copay is $250, and outpatient x-rays copay is $35. The inpatient hospital copay is $250 per day for the first six days. The outpatient hospital copay is $375 per visit. Skilled nursing copays are $0 for the first 20 days and $203 for days 21-100.
The ground ambulance copay is $225 and occupational therapy visits have a $20 copay. Mental health services include: Psychiatric inpatient hospital $400 per day, $20 copay for outpatient group therapy visits, and $20 copay for outpatient individual therapy visits. Durable medical equipment is subject to 20% coinsurance. Hearing exams have a $20 copay and Medicare-covered dental services have a $35 copay. Routine eye exams also have a $20 copay. Contact lenses and eyeglasses have a $0 copay, subject to policy limits.
Chiropractic services have a $15 copay and some acupuncture is covered. Foot exams are subject to a $20 copay. Additional included benefits (subject to policy limitations) include: Drug benefits (over the counter), annual physical exams, telehealth, worldwide emergency coverage and urgent care, telemonitoring services, and fitness benefit.
30-Day Cost-Sharing Preferred Pharmacy prescription drug copays: $0 (Tier 1 Preferred Generic), $5 (Tier 2 Generic), 25% (Tier 3 Preferred Brand), 35% (Tier 4 Non-Preferred Drug), and 33% (Tier 5 Specialty). 90-Day Cost-Sharing Mail-Order prescription drug copays: $0 (Tier 1 Preferred Generic), $15 (Tier 2 Generic), 25% (Tier 3 Preferred Brand), 35% (Tier 4 Non-Preferred Drug), and n/a (Tier 5 Specialty).
Giveback (HMO) – $0 monthly premium and $0 deductible. $8,300 maximum out-of-pocket expenses. 3,375 formulary drugs are offered, and the formulary exception (if approved) is Tier 4. Available drugs per tier are 332 (Tier 1), 601 (Tier 2), 806 (Tier 3), 867 (Tier 4), and 769 (Tier 5). 1,355 members are enrolled in the state, and 1,406 countrywide. The Plan’s Summary Star Rating is 3.5 (4.0 Customer Service).
Doctor visit copays are $0 (primary care physician) and $40 (specialist). Diagnostic tests and procedures copay is $20, lab services copay is $0, diagnostic radiology services copay is $250, and outpatient x-rays copay is $30. The ER and Urgent Care copays are $100 and $15. The inpatient hospital copay is $310 per day for the first five days. The outpatient hospital copay is $350 per visit. Skilled nursing copays are $0 for the first 20 days and $203 for days 21-100.
The ground ambulance copay is $275 and occupational therapy visits have a $40 copay. Mental health services include: Psychiatric inpatient hospital $310 per day for 5 days, $40 copay for outpatient group therapy visits, and $40 copay for outpatient individual therapy visits. Durable medical equipment is subject to 20% coinsurance. Hearing exams have a $40 copay and Medicare-covered dental services have a $40 copay. Routine eye exams also have a $20 copay. Contact lenses and eyeglasses have a $0 copay, subject to policy limits.
Chiropractic services have a $15 copay and some acupuncture is covered. Foot exams are subject to a $20 copay. Additional included benefits (subject to policy limitations) include: Drug benefits (over the counter), annual physical exams, telehealth, worldwide emergency coverage and urgent care, telemonitoring services, and fitness benefit.
30-Day Cost-Sharing Preferred Pharmacy prescription drug copays: $0 (Tier 1 Preferred Generic), $10 (Tier 2 Generic), 20% (Tier 3 Preferred Brand), 35% (Tier 4 Non-Preferred Drug), and 25% (Tier 5 Specialty). 90-Day Cost-Sharing Mail-Order prescription drug copays: $0 (Tier 1 Preferred Generic), $20 (Tier 2 Generic), 20% (Tier 3 Preferred Brand), 35% (Tier 4 Non-Preferred Drug), and n/a (Tier 5 Specialty).
Prime (HMO) – $40.90 monthly premium and $0 deductible. $6,400 maximum out-of-pocket expenses. 3,541 formulary drugs are offered, and the formulary exception (if approved) is Tier 4. Available drugs per tier are 398 (Tier 1), 942 (Tier 2), 572 (Tier 3), 837 (Tier 4), and 792 (Tier 5). 2,627 members are enrolled in the state, and 2,678 countrywide. The Plan’s Summary Star Rating is 3.5 (4.0 Customer Service).
Doctor visit copays are $0 (primary care physician) and $20 (specialist). Diagnostic tests and procedures copay is $10, lab services copay is $0, diagnostic radiology services copay is $250, and outpatient x-rays copay is $25. The ER and Urgent Care copays are $100 and $5. The inpatient hospital copay is $235 per day for the first six days. The outpatient hospital copay is $350 per visit. Skilled nursing copays are $0 for the first 20 days and $203 for days 21-100.
The ground ambulance copay is $250 and occupational therapy visits have a $25 copay. Mental health services include: Psychiatric inpatient hospital $235 per day for 6 days, $20 copay for outpatient group therapy visits, and $20 copay for outpatient individual therapy visits. Durable medical equipment is subject to 20% coinsurance. Hearing exams have a $35 copay and Medicare-covered dental services have a $40 copay. Routine eye exams also have a $40 copay. Contact lenses and eyeglasses have a $0 copay, subject to policy limits.
Chiropractic services have a $15 copay and some acupuncture is covered. Foot exams are subject to a $20 copay. Additional included benefits (subject to policy limitations) include: Drug benefits (over the counter), annual physical exams, telehealth, transportation services, worldwide emergency coverage and urgent care, telemonitoring services, and fitness benefit.
30-Day Cost-Sharing Preferred Pharmacy prescription drug copays: $0 (Tier 1 Preferred Generic), $10 (Tier 2 Generic), 20% (Tier 3 Preferred Brand), 35% (Tier 4 Non-Preferred Drug), and 25% (Tier 5 Specialty). 90-Day Cost-Sharing Mail-Order prescription drug copays: $0 (Tier 1 Preferred Generic), $20 (Tier 2 Generic), 20% (Tier 3 Preferred Brand), 35% (Tier 4 Non-Preferred Drug), and n/a (Tier 5 Specialty).
Special (HMO) – $0 monthly premium and $0 deductible. $8,850 maximum out-of-pocket expenses. 3,532 formulary drugs are offered. Available drugs per tier are not available. 7,474 members are enrolled in the state, and 7,547 countrywide. The Plan’s Summary Star Rating is 3.5 (4.0 Customer Service).
Doctor visit copays are $0 or 20% (primary care physician) and $0 or 20% (specialist). Diagnostic tests and procedures copay is $0 or 20%, lab services copay is $0 or 20%, diagnostic radiology services copay is $0 or 20%, and outpatient x-rays copay is $0 or 20%. The ER and Urgent Care copays are $0 or 20%, or up to $110 and $45. The inpatient hospital copay is $0. The outpatient hospital copay is $0 or 20%. Skilled nursing requires authorization.
The ground ambulance copay is $0 or 20% and occupational therapy visits have a $0 or 20% copay. Mental health services include: Psychiatric inpatient hospital, $0 or 20% copay for outpatient group therapy visits, and $0 or 20% copay for outpatient individual therapy visits. Durable medical equipment is subject to $0 or 20% coinsurance. Hearing exams have a $0 or 20% copay and Medicare-covered dental services have a $0 copay. Routine eye exams also have a $0 copay. Contact lenses and eyeglasses have a $0 copay, subject to policy limits.
Chiropractic services have a 20% copay and some acupuncture is covered. Foot exams are subject to a $0 or 20%copay. Additional included benefits (subject to policy limitations) include: Transportation services, drug benefits (over the counter), short duration meals, annual physical exams, telehealth, and fitness benefit.
30-Day Cost-Sharing Preferred Pharmacy prescription drug copays: 25% (Tier 1 Preferred Generic), 25% (Tier 2 Generic), 25% (Tier 3 Preferred Brand), 25% (Tier 4 Non-Preferred Drug), and 25% (Tier 5 Specialty). 90-Day Cost-Sharing Mail-Order prescription drug copays: 25% (Tier 1 Preferred Generic), 25% (Tier 2 Generic), 25% (Tier 3 Preferred Brand), 25% (Tier 4 Non-Preferred Drug), and 25% (Tier 5 Specialty).
Note: Jefferson does not offer Part D prescription drug plans in Pennsylvania.
Additional Member Perks And Benefits
Paying Your Premium – Paying online is a popular option. The setup process is simple and continuous recurring bills can be set up without paying an extra fee. A portal is provided to help create a billing account. Both PPO and HMO plans can be paid online. A grace period is provided if the premium is not paid by the first of the month.
Denial Of Coverage – Medical services and prescription drug payments that have been denied, can be appealed. The Member Relations Department will attempt to settle the disagreement and assist the policyholder. disagreements can be filed by phone or in writing. The Pa Department of insurance also provides a separate appeal form.
Health Survey – A survey is provided that helps develop programs for customers to better serve their needs.
Resources For Members – A “Summary Of Benefits” is provided to help understand all benefits and coverage of your plan. This includes copays, coinsurance, deductibles, and maximum out-of-pocket expenses. The member handbook provides additional details including contact information, essential health benefits, and rights and responsibilities.
