Jefferson Health Plans Preferred (PPO)
Available to residents of Monroe County, PA for 2027. Contract H1619, plan 004, segment 0.
- ✉ Email a copy of the plan benefit details
- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Monroe County
- Plan website
- Browse the Jefferson Health Plans Preferred (PPO) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
New for 2027. This plan has no 2026 predecessor in the CMS crosswalk. Every PA plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $40.00 |
|---|---|
| — medical (Part C) part | $26.30 |
| — drug (Part D) part | $13.70? |
| Monthly premium with full Extra Help (LIS) | $27.20?drug (Part D) part $0.90; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $6,500.00? |
| In- and out-of-network out-of-pocket maximum | $10,000.00 |
| Drug deductible | $0.00 |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | PPO? |
| Contract / plan | H1619-004-0 |
| Offered by | Jefferson Health Plans |
| Parent organization | Thomas Jefferson University |
| Formulary tiers | 5 |
| Formulary exception tier | 4? |
| Pharmacy search | JeffersonHealthPlans.com/medicare |
| Member services | (833)477-4773TTY (877)454-8477 |
CMS star ratings
- Overall
- 3 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 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H1619 shares this rating.
Plan health benefits
| Service | In-network | Out-of-network? |
|---|---|---|
| Doctor visits | ||
| Primary care doctor | $0 copay | $0 copay |
| Specialist | $20 copay | $20 copay |
| Other health care professional | $0–$20 copay | $0–$20 copay |
| Additional telehealth services | $0–$20 copay | — |
| Preventive care | ||
| Medicare-covered preventive services | $0 copay(authorization required) | $0 copay |
| Annual physical exam | $0 copay | $0 copay |
| Kidney disease education | $0 copay | $0 copay |
| Glaucoma screening | $0 copay | $0 copay |
| Diabetes self-management training | $0 copay | $0 copay |
| Diagnostic tests, labs and imaging | ||
| Diagnostic tests and procedures | $0 copay(authorization required) | $0 copay |
| Lab services | $0 copay(authorization required) | $0 copay |
| Diagnostic radiology (e.g. MRI, CT) | $250 copay(authorization required) | $250 copay |
| Therapeutic radiology | 20% coinsurance(authorization required) | 20% coinsurance |
| Outpatient x-rays | $35 copay(authorization required) | $35 copay |
| Emergency and urgent care | ||
| Emergency room | $100 copay | — |
| Urgent care | $10 copay | — |
| 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 | $350 per stay(authorization required) | $350 per stay |
| Outpatient hospital services | $250 copay(authorization required) | $250 copay |
| Outpatient observation | $250 copay | $250 copay |
| Ambulatory surgical center | $150 copay(authorization required) | $150 copay |
| Outpatient blood services | $0 copay | $0 copay |
| Skilled nursing and home health | ||
| Skilled nursing facility | $0 per day for days 1–20; $203 per day for days 21–100(authorization required) | $0 per day for days 1–20; $203 per day for days 21–100 |
| Home health care | $0 copay(authorization required) | $0 copay |
| Kidney dialysis | 20% coinsurance | 20% coinsurance |
| Rehabilitation | ||
| Occupational therapy | $20 copay(authorization required) | $20 copay |
| Physical therapy and speech-language therapy | $20 copay(authorization required) | $20 copay |
| Cardiac rehabilitation | $0 copay | $0 copay |
| Pulmonary rehabilitation | $0 copay | $0 copay |
| Mental health and substance use | ||
| Inpatient psychiatric hospital stay | $350 per stay(authorization required) | $350 per stay; $800 per day for days 1–90 |
| Outpatient mental health, individual session | $20 copay(authorization required) | $20 copay |
| Outpatient mental health, group session | $20 copay(authorization required) | $20 copay |
| Psychiatrist, individual session | $20 copay(authorization required) | $20 copay |
| Psychiatrist, group session | $20 copay(authorization required) | $20 copay |
| Partial hospitalization | $70 copay(authorization required) | $70 copay |
| Intensive outpatient program | $70 copay | $70 copay |
| Outpatient substance use, individual session | $20 copay | $20 copay |
| Outpatient substance use, group session | $20 copay | $20 copay |
| Opioid treatment program | $20 copay | $20 copay |
| Ambulance and transportation | ||
| Ground ambulance | $250 copay(authorization required) | $250 copay |
| Air ambulance | 20% coinsurance(authorization required) | 20% coinsurance |
| Transportation to plan-approved locations | $0 copay(limits apply) | $0 copay |
| Medical equipment and supplies | ||
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) | 20% coinsurance |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) | 20% coinsurance |
| Medical supplies | 20% coinsurance(authorization required) | 20% coinsurance |
| Diabetes supplies | 0%–20% coinsurance(authorization required) | 0%–20% coinsurance |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) | 20% coinsurance |
| Chiropractic, acupuncture and foot care | ||
| Chiropractic (Medicare-covered) | $15 copay(authorization required) | $15 copay |
| Routine chiropractic care | $20 copay(authorization required, limits apply) | $20 copay |
| Acupuncture | $0 copay(limits apply) | $0 copay |
| Foot exams and treatment (Medicare-covered) | $20 copay | $20 copay |
| Routine foot care | $20 copay(limits apply) | $20 copay |
| Dental? | ||
| Medicare-covered dental services | $20 copay | $20 copay |
| Preventive dental plan limit | $1,450 plan limit every year | — |
| Oral exams | $0 copay(limits apply) | $0 copay |
| Cleanings | $0 copay(limits apply) | $0 copay |
| Fluoride treatment | Not covered | — |
| Dental x-rays | $0 copay(limits apply) | $0 copay |
| Other diagnostic dental services | $0 copay(limits apply) | $0 copay |
| Other preventive dental services | $0 copay(limits apply) | $0 copay |
| Restorative services (fillings, crowns) | $0 copay | 50% coinsurance |
| Endodontics (root canals) | $0 copay | 50% coinsurance |
| Periodontics (gum disease) | $0 copay | 50% coinsurance |
| Dentures and other removable prosthodontics | $0 copay | 50% coinsurance |
| Maxillofacial prosthetics | $0 copay | 50% coinsurance |
| Implants | Not covered | — |
| Bridges and other fixed prosthodontics | $0 copay | 50% coinsurance |
| Oral and maxillofacial surgery | $0 copay | 50% coinsurance |
| Orthodontics | Not covered | — |
| Adjunctive general services | Not covered | — |
| Vision? | ||
| Eye exam (Medicare-covered) | $0 copay | — |
| Routine eye exam | $0 copay(limits apply) | $0 copay |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) | — |
| Contact lenses | $0 copay(limits apply) | $0 copay |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) | $0 copay |
| Eyeglass lenses | Not covered | — |
| Eyeglass frames | Not covered | — |
| Eyewear upgrades | Not covered | — |
| Hearing? | ||
| Hearing exam (Medicare-covered) | $20 copay | $20 copay |
| Routine hearing exam | $0 copay(limits apply) | $0 copay |
| Hearing aid fitting and evaluation | Not covered | — |
| Hearing aids (all types) | $500–$1,975 copay(limits apply) | $500–$1,975 copay |
| 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) | 0%–20% coinsurance |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 0%–20% coinsurance |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 0%–20% coinsurance |
| Other extra benefits? | ||
| Over-the-counter (OTC) allowance | $75 allowance every three months | — |
| Meals after a hospital stay or for a chronic condition | Not covered | — |
| Fitness benefit | $0 copay(limits apply) | $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(limits apply) | $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, CY2027). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $0.00 |
| Tier 3 · Preferred Brand | 25% |
| Tier 4 · Non-Preferred Drug | 31% |
| Tier 5 · Specialty Tier | 33% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial 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 | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 4: Non-Preferred Drug | 31% | 31% | 31% | 31% | 31% | 31% |
| Tier 5: Specialty Tier | 33% | 33% | 33% | n/a | n/a | n/a |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Staying Healthy: Screenings, Tests and Vaccines | ||
| Colorectal Cancer Screening · C02 | 1 out of 5 stars for Colorectal Cancer Screening | Plan too small to be measured |
| Annual Flu Vaccine · C03 | 4 out of 5 stars for Annual Flu Vaccine | Plan too small to be measured |
| Monitoring Physical Activity · C06 | 4 out of 5 stars for Monitoring Physical Activity | too new |
| Managing Chronic (Long Term) Conditions | ||
| Diabetes Care – Eye Exam · C11 | 3 out of 5 stars for Diabetes Care – Eye Exam | Plan too small to be measured |
| Diabetes Care – Blood Sugar Controlled · C12 | 3 out of 5 stars for Diabetes Care – Blood Sugar Controlled | Plan too small to be measured |
| Kidney Health Evaluation for Patients with Diabetes · C13 | 4 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes | Plan too small to be measured |
| Controlling High Blood Pressure · C14 | 2 out of 5 stars for Controlling High Blood Pressure | Plan too small to be measured |
| Reducing the Risk of Falling · C15 | 1 out of 5 stars for Reducing the Risk of Falling | too new |
| Improving Bladder Control · C16 | 5 out of 5 stars for Improving Bladder Control | too new |
| Transitions of Care · C19 | 3 out of 5 stars for Transitions of Care | Plan too small to be measured |
| Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions · C20 | 1 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions | Plan too small to be measured |
| Member Experience with Health Plan | ||
| Getting Needed Care · C21 | 4 out of 5 stars for Getting Needed Care | Plan too small to be measured |
| Getting Appointments and Care Quickly · C22 | 4 out of 5 stars for Getting Appointments and Care Quickly | Plan too small to be measured |
| Customer Service · C23 | 3 out of 5 stars for Customer Service | Plan too small to be measured |
| Rating of Health Care Quality · C24 | 5 out of 5 stars for Rating of Health Care Quality | Plan too small to be measured |
| Rating of Health Plan · C25 | 4 out of 5 stars for Rating of Health Plan | Plan too small to be measured |
| Care Coordination · C26 | 4 out of 5 stars for Care Coordination | Plan too small to be measured |
| Member Complaints and Changes in the Health Plan's Performance | ||
| Complaints about the Health Plan · C27 | 3 out of 5 stars for Complaints about the Health Plan | not enough data |
| Members Choosing to Leave the Plan · C28 | 3 out of 5 stars for Members Choosing to Leave the Plan | not enough data |
| Health Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · C32 | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 3 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD1: Drug Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · D01 | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD2: Member Complaints and Changes in the Drug Plan’s Performance | ||
| Complaints about the Drug Plan · D02 | 3 out of 5 stars for Complaints about the Drug Plan | not enough data |
| Members Choosing to Leave the Plan · D03 | 3 out of 5 stars for Members Choosing to Leave the Plan | not enough data |
| Drug Plan Quality Improvement · D04 | 2 out of 5 stars for Drug Plan Quality Improvement | not enough data |
| DD3: Member Experience with the Drug Plan | ||
| Rating of Drug Plan · D05 | 4 out of 5 stars for Rating of Drug Plan | Plan too small to be measured |
| Getting Needed Prescription Drugs · D06 | 4 out of 5 stars for Getting Needed Prescription Drugs | Plan too small to be measured |
| DD4: Drug Safety and Accuracy of Drug Pricing | ||
| MPF Price Accuracy · D07 | 3 out of 5 stars for MPF Price Accuracy | 5 out of 5 stars for MPF Price Accuracy |
| Medication Adherence for Diabetes Medications · D08 | 2 out of 5 stars for Medication Adherence for Diabetes Medications | 4 out of 5 stars for Medication Adherence for Diabetes Medications |
| Medication Adherence for Hypertension (RAS antagonists) · D09 | 3 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) | 3 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) |
| Medication Adherence for Cholesterol (Statins) · D10 | 2 out of 5 stars for Medication Adherence for Cholesterol (Statins) | 3 out of 5 stars for Medication Adherence for Cholesterol (Statins) |
| Statin Use in Persons with Diabetes (SUPD) · D11 | 3 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) | 4 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) |
| Concurrent Use of Opioids and Benzodiazepines (COB) · D12 | 2 out of 5 stars for Concurrent Use of Opioids and Benzodiazepines (COB) | new measure |
| Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) · D13 | 5 out of 5 stars for Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) | new measure |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H1619 shares it.
Also available in 19 other PA counties
Benefits in plain text
Jefferson Health Plans Preferred (PPO) (H1619-004-0) is a 2027 PPO Medicare Advantage plan offered by Jefferson Health Plans, available to residents of Monroe County, PA.
The monthly premium is $40.00.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $27.20.
Its in-network out-of-pocket maximum is $6,500.00.
The combined in- and out-of-network out-of-pocket maximum is $10,000.00.
The drug deductible is $0.00.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $0.00; tier 3 (Preferred Brand): 25%; tier 4 (Non-Preferred Drug): 31%; tier 5 (Specialty Tier): 33%.
CMS gives the plan's contract (H1619) an overall rating of 3 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.