Jefferson Health Plans Special (HMO D-SNP)
Available to residents of Erie County, PA for 2026. Contract H9207, plan 004, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Erie County
- Plan website
- Browse the Jefferson Health Plans Special (HMO D-SNP) formulary
Renewed, service area expanded for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $32.70 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $32.70? |
| Drug premium in CMS's quarterly plan file | $0.00The CMS Landscape file above lists $32.70 for the drug part; the two CMS files differ for this plan. |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $9,250.00? |
| Drug deductible | $615.00Tier 1 and 6 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO D-SNP? |
| Special needs plan | Dual-eligible SNP |
| Contract / plan | H9207-004-0 |
| Offered by | Jefferson Health Plans |
| Parent organization | Thomas Jefferson University |
| Formulary drugs | 3,426 |
| Formulary exception tier | 4? |
| Pharmacy search | JeffersonHealthPlans.com/medicare |
| Member services | (833)477-4773TTY (877)454-8477 |
CMS star ratings
- Overall
- 3.5 out of 5 stars for Overall
- Health plan (Part C)
- 3.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 3.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H9207 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | 20% coinsurance |
| Specialist | 20% coinsurance |
| Other health care professional | 20% coinsurance |
| Additional telehealth services | 30% coinsurance |
| Preventive care | |
| Medicare-covered preventive services | $0 copay(authorization required) |
| Annual physical exam | 20% coinsurance |
| Kidney disease education | 20% coinsurance |
| Glaucoma screening | 30% coinsurance |
| Diabetes self-management training | 30% coinsurance |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | 30% coinsurance(authorization required) |
| Lab services | 30% coinsurance(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | 30% coinsurance(authorization required) |
| Therapeutic radiology | 20% coinsurance(authorization required) |
| Outpatient x-rays | 30% coinsurance(authorization required) |
| Emergency and urgent care | |
| Emergency room | 30% coinsurance |
| Urgent care | 30% coinsurance |
| Worldwide emergency coverage | $0 copay · $50,000 plan limit |
| Worldwide urgent care | $0 copay · $50,000 plan limit |
| Worldwide emergency transportation | Not covered |
| Hospital care | |
| Inpatient hospital stay | $1,690 per stay(authorization required) |
| Outpatient hospital services | 30% coinsurance(authorization required) |
| Outpatient observation | 30% coinsurance |
| Ambulatory surgical center | 30% coinsurance(authorization required) |
| Outpatient blood services | 30% coinsurance |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $218 per day for days 21–100(authorization required) |
| Home health care | $0 copay(authorization required) |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | 30% coinsurance(authorization required) |
| Physical therapy and speech-language therapy | 30% coinsurance(authorization required) |
| Cardiac rehabilitation | 30% coinsurance |
| Pulmonary rehabilitation | 30% coinsurance |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $2,080 per stay(authorization required) |
| Outpatient mental health, individual session | 30% coinsurance(authorization required) |
| Outpatient mental health, group session | 30% coinsurance(authorization required) |
| Psychiatrist, individual session | 30% coinsurance(authorization required) |
| Psychiatrist, group session | 30% coinsurance(authorization required) |
| Partial hospitalization | 30% coinsurance(authorization required) |
| Intensive outpatient program | 30% coinsurance |
| Outpatient substance use, individual session | 30% coinsurance |
| Outpatient substance use, group session | 30% coinsurance |
| Opioid treatment program | 30% coinsurance |
| Ambulance and transportation | |
| Ground ambulance | 30% coinsurance(authorization required) |
| Air ambulance | 30% coinsurance(authorization required) |
| Transportation to plan-approved locations | $0 copay(limits apply) |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | 20% coinsurance(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | 30% coinsurance(authorization required) |
| Routine chiropractic care | Not covered |
| Acupuncture | $0 copay(limits apply) |
| Foot exams and treatment (Medicare-covered) | 30% coinsurance |
| Routine foot care | $0 copay(limits apply) |
| Dental? | |
| Medicare-covered dental services | $0 copay |
| Oral exams | $0 copay(authorization required, limits apply) |
| Cleanings | $0 copay(authorization required, limits apply) |
| Fluoride treatment | Not covered |
| Dental x-rays | $0 copay(authorization required, limits apply) |
| Other diagnostic dental services | $0 copay(authorization required) |
| Other preventive dental services | $0 copay(authorization required) |
| Comprehensive dental plan limit | $5,000 plan limit every year |
| Restorative services (fillings, crowns) | $0 copay |
| Endodontics (root canals) | $0 copay |
| Periodontics (gum disease) | $0 copay |
| Dentures and other removable prosthodontics | $0 copay |
| Maxillofacial prosthetics | $0 copay |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | $0 copay |
| Oral and maxillofacial surgery | $0 copay |
| Orthodontics | Not covered |
| Adjunctive general services | Not covered |
| Vision? | |
| Eye exam (Medicare-covered) | 30% coinsurance |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | Not covered |
| Eyeglass frames | Not covered |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | 30% coinsurance |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | Not covered |
| Hearing aids (all types) | $0–$1,475 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $250 allowance every three months |
| Meals after a hospital stay or for a chronic condition | $0 copay |
| Fitness benefit | $0 copay |
| Health education | Not covered |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | $0 copay |
| Remote access technologies (web/phone, nurse line) | Not covered |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | 20% |
| Tier 3 | 24% |
| Tier 4 | 28% |
| Tier 5 | 25% |
| Tier 6 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | 20% | 20% | 20% | 20% | 20% | 20% |
| Tier 3: Preferred Brand | 24% | 24% | 24% | 24% | 24% | 24% |
| Tier 4: Non-Preferred Drug | 28% | 28% | 28% | 28% | 28% | 28% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 27 other PA counties
Benefits in plain text
Jefferson Health Plans Special (HMO D-SNP) (H9207-004-0) is a 2026 HMO D-SNP Medicare Advantage plan offered by Jefferson Health Plans, available to residents of Erie County, PA.
The monthly premium is $32.70 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
Its in-network out-of-pocket maximum is $9,250.00.
The drug deductible is $615.00. Tier 1 and 6 exempt.
It is a special needs plan (Dual-eligible SNP).
The plan's formulary lists 3,426 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: 20%; tier 3: 24%; tier 4: 28%; tier 5: 25%; tier 6: $0.00.
CMS gives the plan's contract (H9207) an overall rating of 3.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.