Clover Health Premier (PPO) is a Medicare Advantage (Part C) Plan by Clover Health.
This page features plan details for 2023 Clover Health Premier (PPO) H5141 – 054 – 0 available in Select NJ Counties.
IMPORTANT: This page has been updated with plan and premium data for the 2023.
Clover Health Premier (PPO) is offered in the following locations.
Clover Health Premier (PPO) offers the following coverage and cost-sharing.
Insurer: | Clover Health |
Health Plan Deductible: | $0.00 |
MOOP: | $12,450 In and Out-of-network $8,300 In-network |
Drugs Covered: | Yes |
Ready to sign up for Clover Health Premier (PPO) ?
Get help from a licensed Medicare agent.
Click to Call 1-877-354-4611 TTY 711. Mon-Fri 8am-9pm EST | Sat 8am-8pm EST.
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 $75.00.
Premium Reduction: | $75.00 |
Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$164.90 | $0.00 | $0.00 | $75.00 | $89.90 |
Clover Health Premier (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Deductible: | $300.00 |
Initial Coverage Limit: | $4,660.00 |
Catastrophic Coverage Limit: | $7,400.00 |
Drug Benefit Type: | Enhanced |
Gap Coverage: | No |
Formulary Link: | Formulary Link |
Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
---|---|---|---|---|
$0.00 | $ | $ | $ | $ |
After you pay your $300.00 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 $4,660.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $12.00 copay | ||
2 (Generic) | 22% | 25% | ||
3 (Preferred Brand) | 22% | 25% | ||
4 (Non-Preferred Drug) | 25% | 25% | ||
5 (Specialty Tier) | 25% | 25% |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | ||||
2 (Generic) | ||||
3 (Preferred Brand) | ||||
4 (Non-Preferred Drug) | ||||
5 (Specialty Tier) |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $5.00 copay | $0.00 copay | |
2 (Generic) | 22% | 25% | 0% | |
3 (Preferred Brand) | 22% | 25% | 22% | |
4 (Non-Preferred Drug) | 25% | 25% | 25% | |
5 (Specialty Tier) | 25% | 25% | 25% |
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
Tier | Cost |
---|---|
All other tiers (Generic) | 25% |
All other tiers (Brand-name) | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
Drug Type | Cost Share |
---|---|
Generic drugs | $4.15 copay or 5% (whichever costs more) |
Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Clover Health Premier (PPO) also provides the following benefits.
In-Network: No |
Diagnostic services: | Not covered (no limits) |
Endodontics: | Not covered (no limits) |
Extractions: | Not covered (no limits) |
Non-routine services: | Not covered (no limits) |
Periodontics: | Not covered (no limits) |
Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered (no limits) |
Restorative services: | Not covered (no limits) |
Cleaning: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Cleaning: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Dental x-ray(s): | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Dental x-ray(s): | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Fluoride treatment: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Fluoride treatment: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Oral exam: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Oral exam: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Diagnostic radiology services (e.g., MRI): | In-Network: $0-350 copay (authorization required) (referral not required) |
Diagnostic radiology services (e.g., MRI): | Out-of-Network: 40% coinsurance (authorization required) (referral not required) |
Diagnostic tests and procedures: | In-Network: $0-175 copay (authorization required) (referral not required) |
Diagnostic tests and procedures: | Out-of-Network: 40% coinsurance (authorization required) (referral not required) |
Lab services: | In-Network: $0-10 copay (authorization required) (referral not required) |
Lab services: | Out-of-Network: 0-40% coinsurance (authorization required) (referral not required) |
Outpatient x-rays: | In-Network: $40 copay (authorization required) (referral not required) |
Outpatient x-rays: | Out-of-Network: 40% coinsurance (authorization required) (referral not required) |
Primary: | In-Network: $0 copay |
Primary: | Out-of-Network: $0 copay |
Specialist: | In-Network: $35 copay per visit (authorization not required) (referral not required) |
Specialist: | Out-of-Network: $65 copay per visit (authorization not required) (referral not required) |
Emergency: | $95 copay per visit (always covered) |
Urgent care: | $40 copay per visit (always covered) |
Foot exams and treatment: | In-Network: $40 copay (authorization not required) (referral not required) |
Foot exams and treatment: | Out-of-Network: $65 copay (authorization not required) (referral not required) |
Routine foot care: | Not covered |
In-Network: $310 copay | |
Out-of-Network: $310 copay |
$0.00 |
In-Network: No |
Fitting/evaluation: | Not covered (no limits) |
Hearing aids: | In-Network: $699-999 copay (limits may apply) (authorization not required) (referral not required) |
Hearing aids: | Out-of-Network: $999 copay (limits may apply) (authorization not required) (referral not required) |
Hearing exam: | In-Network: $40 copay (authorization not required) (referral not required) |
Hearing exam: | Out-of-Network: $65 copay (authorization not required) (referral not required) |
In-Network: $390 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) | |
Out-of-Network: $595 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) |
In-Network: $350 copay per visit (authorization required) (referral not required) | |
Out-of-Network: 40% coinsurance per visit (authorization required) (referral not required) |
$12,450 In and Out-of-network $8,300 In-network |
Diabetes supplies: | In-Network: $0 copay (authorization not required) |
Diabetes supplies: | Out-of-Network: 20% coinsurance per item (authorization not required) |
Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 20% coinsurance per item (authorization required) |
Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 30% coinsurance per item (authorization required) |
Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization required) |
Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 30% coinsurance per item (authorization required) |
Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
Chemotherapy: | Out-of-Network: 40% coinsurance (authorization required) |
Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
Other Part B drugs: | Out-of-Network: 40% coinsurance (authorization required) |
Inpatient hospital – psychiatric: | In-Network: $370 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) |
Inpatient hospital – psychiatric: | Out-of-Network: $575 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) |
Outpatient group therapy visit: | In-Network: $40 copay (authorization required) (referral not required) |
Outpatient group therapy visit: | Out-of-Network: $65 copay (authorization required) (referral not required) |
Outpatient group therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) (referral not required) |
Outpatient group therapy visit with a psychiatrist: | Out-of-Network: $65 copay (authorization required) (referral not required) |
Outpatient individual therapy visit: | In-Network: $40 copay (authorization required) (referral not required) |
Outpatient individual therapy visit: | Out-of-Network: $65 copay (authorization required) (referral not required) |
Outpatient individual therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) (referral not required) |
Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: $65 copay (authorization required) (referral not required) |
No |
In-Network: $0 copay (authorization not required) (referral not required) | |
Out-of-Network: $0 copay (authorization not required) (referral not required) |
Occupational therapy visit: | In-Network: $40 copay (authorization required) (referral not required) |
Occupational therapy visit: | Out-of-Network: $65 copay (authorization required) (referral not required) |
Physical therapy and speech and language therapy visit: | In-Network: $40 copay (authorization required) (referral not required) |
Physical therapy and speech and language therapy visit: | Out-of-Network: $65 copay (authorization required) (referral not required) |
In-Network: $0 per day for days 1 through 20 $196 per day for days 21 through 100 (authorization required) (referral not required) | |
Out-of-Network: 40% per stay (authorization required) (referral not required) |
Not covered |
Contact lenses: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Contact lenses: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Eyeglass frames: | Not covered (no limits) |
Eyeglass lenses: | Not covered (no limits) |
Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Eyeglasses (frames and lenses): | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Other: | Not covered (no limits) |
Routine eye exam: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Routine eye exam: | Out-of-Network: 40% coinsurance (limits may apply) (authorization not required) (referral not required) |
Upgrades: | Not covered |
Covered (authorization not required) (referral not required) |
Ready to sign up for Clover Health Premier (PPO) ?
Get help from a licensed Medicare agent.
Click to Call 1-877-354-4611 TTY 711. Mon-Fri 8am-9pm EST | Sat 8am-8pm EST.
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