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Clover Health Premier (PPO)

H5141 - 054 - 0

(4 / 5)

Clover Health Premier (PPO) is a Medicare Advantage Plan by Clover Health.

This page features plan details for 2025 Clover Health Premier (PPO) H5141 – 054 – 0.

IMPORTANT: This page features the 2025 version of this plan. See the 2025 version using the link below:

2025 Clover Health Premier (PPO) H5141 - 054 - 0

Locations

Clover Health Premier (PPO) is offered in the following locations.

Atlantic County, New Jersey

Bergen County, New Jersey

Burlington County, New Jersey

Click to see more locations

Plan Overview

Clover Health Premier (PPO) offers the following coverage and cost-sharing.

Insurer:	Clover Health
Health Plan Deductible:	$0
MOOP:	$12,999 In and Out-of-network $8,499 In-network
Drugs Covered:	Yes

Ready to sign up for Clover Health Premier (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.

Clover Health Premier (PPO) qualifies for a monthly Medicare Give Back Benefit of $100.00.

Premium Reduction:

$100.00

Premium Breakdown

Clover Health Premier (PPO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$0.00	$0.00	$100.00	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Clover Health Premier (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$200.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $200.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

60 Day

90 Day

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

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

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: No

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – No Copay
- Out-of-Network: No Coins – No Copay
Fluoride Treatment
- In-Network: No Coins – No Copay
- Out-of-Network: No Coins – No Copay
Oral Exams
- In-Network: No Coins – No Copay
- Out-of-Network: No Coins – No Copay
Other Diagnostic Dental Services
- In-Network: No Coins – No Copay
- Out-of-Network: No Coins – No Copay
Other Preventive Dental Services
- In-Network: No Coins – No Copay
- Out-of-Network: No Coins – No Copay
Prophylaxis (cleaning)
- In-Network: No Coins – No Copay
- Out-of-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

Diagnostic radiology services (e.g., MRI)
- Out-of-Network: $80-600 copay (Authorization Required)
Diagnostic tests and procedures
- Out-of-Network: $0-600 copay (Authorization Required)
Outpatient x-rays
- In-Network: $30 copay (Authorization Required)
- Out-of-Network: $60 copay (Authorization Required)
Diagnostic radiology services (e.g., MRI)
- In-Network: $50-350 copay (Authorization Required)
Diagnostic tests and procedures
- In-Network: $0-350 copay (Authorization Required)
Lab services
- In-Network: $0-20 copay (Authorization Required)
- Out-of-Network: $0-40 copay (Authorization Required)

Doctor visits

Primary
- In-Network: $0 copay
- Out-of-Network: $0 copay
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
- $40 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment
- In-Network: $40 copay
- Out-of-Network: $65 copay
Routine foot care
- Not covered

Ground ambulance

- In-Network: $350 copay
- Out-of-Network: $350 copay

Health plan deductible

- $0

Hearing

Hearing aids OTC
- Not covered
Fitting/evaluation
- Out-of-Network: 40% coinsurance
Hearing aids
- In-Network: $699-999 copay (Limits Apply)
Medicare-Covered Hearing Exam
- In-Network: $35 copay
Fitting/evaluation
- In-Network: $0 copay
Hearing aids
- Out-of-Network: $999 copay (Limits Apply)
Medicare-Covered Hearing Exam
- Out-of-Network: $50 copay

Inpatient hospital coverage

- Out-of-Network: $495 per day for days 1 through 6
  $0 per day for days 7 through 90 (Authorization Required)
- In-Network: $350 per day for days 1 through 6
  $0 per day for days 7 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $12,999 In and Out-of-network
  $8,499 In-network

Medical equipment/supplies

Durable medical equipment (e.g., wheelchairs, oxygen)
- Out-of-Network: 20% coinsurance per item (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- Out-of-Network: 20% coinsurance per item (Authorization Required)
Diabetes supplies
- In-Network: $0 copay
- Out-of-Network: 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)
- In-Network: 20% coinsurance per item (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- In-Network: 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

Chemotherapy
- In-Network: 0-20% coinsurance (Authorization Required)
Other Part B drugs
- In-Network: 0-20% coinsurance (Authorization Required)
Chemotherapy
- Out-of-Network: 40% coinsurance (Authorization Required)
Other Part B drugs
- Out-of-Network: 40% coinsurance (Authorization Required)

Mental health services

Inpatient hospital – psychiatric
- In-Network: $320 per day for days 1 through 6
  $0 per day for days 7 through 90 (Authorization Required)
Outpatient group therapy visit
- Out-of-Network: $65-75 copay
Outpatient group therapy visit with a psychiatrist
- Out-of-Network: $65-75 copay
Inpatient hospital – psychiatric
- Out-of-Network: $495 per day for days 1 through 6
  $0 per day for days 7 through 90 (Authorization Required)
Outpatient individual therapy visit with a psychiatrist
- Out-of-Network: $65-75 copay
Outpatient group therapy visit
- In-Network: $35 copay
Outpatient group therapy visit with a psychiatrist
- In-Network: $35 copay
Outpatient individual therapy visit
- In-Network: $45 copay
- Out-of-Network: $65-75 copay
Outpatient individual therapy visit with a psychiatrist
- In-Network: $45 copay

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- In-Network: $450 copay per visit (Authorization Required)
- Out-of-Network: $595 copay per visit (Authorization Required)

Preventive care

- Out-of-Network: $0 copay
- In-Network: $0 copay

Rehabilitation services

Occupational therapy visit
- In-Network: $35 copay (Authorization Required)
- Out-of-Network: $65 copay (Authorization Required)
Physical therapy and speech and language therapy visit
- In-Network: $35 copay (Authorization Required)
- Out-of-Network: $65 copay (Authorization Required)

Skilled Nursing Facility

- In-Network: $0 per day for days 1 through 20
  $203 per day for days 21 through 100 (Authorization Required)
- Out-of-Network: 40% per stay (Authorization Required)

Transportation

- Not covered

Vision

Contact lenses
- In-Network: $0 copay (Limits Apply)
Eyeglass lenses
- Not covered
Routine eye exam
- In-Network: $0 copay (Limits Apply)
Contact lenses
- Out-of-Network: $0 copay (Limits Apply)
Eyeglasses (frames and lenses)
- In-Network: $0 copay (Limits Apply)
Upgrades
- Not covered
Eyeglasses (frames and lenses)
- Out-of-Network: $0 copay (Limits Apply)
Eyeglass frames
- Not covered
Other
- Not covered
Routine eye exam
- Out-of-Network: 40% coinsurance (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

- Covered