4

4 out of 5 stars* for plan year 2024

Plan ID: H5141-047

What You Need to Know:

  • Clover Health Choice Value (PPO) is a Medicare Advantage Health Maintenance Organization Local PPO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $30, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is $445 (Tier 1 excluded from the Deductible.).
  • The plan includes an out-of-pocket maximum of $7,550 per year (in-network).
  • Clover Health Choice Value (PPO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is $445 (Tier 1 excluded from the Deductible.).
  • This plan's Part D Initial Coverage Limit is $30.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$30

Monthly Premium

Medicare Plan Features
Monthly Premium: $29.80
Part C Premium: $0
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$29.80 $0 $29.80 $0 $29.80 $445.0 1.0
Gap Coverage: No
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local PPO
Similar Plan: H5141-048
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: No additional gap coverage, only the Donut Hole Discount
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $7,550
Annual Deductible: $445 (Tier 1 excluded from the Deductible.)
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Evans, Georgia: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
less than 10 members 3 out of 5 Stars. 4 out of 5 Stars. 3 out of 5 Stars.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 3,407 drugs
Number of Members Enrolled in this Plan in Evans, Georgia: 60 members
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$0.00 $29.80 $0.00 $29.80
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$0.00 $22.30 $22.30 $14.90 $14.90 $7.40 $7.40
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
365 $0.00 462 22% 1032 22% 872 25% 676 25%

Other Medicare Advantage Plans in Evans, Georgia

Plan Name Type Premium MOOP Rx Deduct. Rating
HumanaChoice H5216-207 (PPO) (2023)Local PPO$7,550$75
4
Humana Honor (PPO) (2023)Local PPO *$6,700$-
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HumanaChoice R3392-001 (Regional PPO) (2023)Regional PPO *$6,700$-
4
AARP Medicare Advantage Plus Plan 1 (HMO-POS) (2023)Local HMO$6,700$275
5
UnitedHealthcare Medicare Advantage Patriot (Regional PPO (2023)Regional PPO *$6,700$-
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HumanaChoice R3392-002 (Regional PPO) (2023)Regional PPO$6,700$340
4
UnitedHealthcare Medicare Advantage Choice (Regional PPO) (2023)Regional PPO$6,700$295
5
Anthem MediBlue Access Basic (PPO) (2023)Local PPO$6,700$150
4
AARP Medicare Advantage Plus Plan 2 (HMO-POS) (2023)Local HMO$4,900$175
5
HumanaChoice H5216-157 (PPO) (2023)Local PPO *$6,700$-
4
Anthem MediBlue Access (PPO) (2023)Local PPO$5,900$95
4
UnitedHealthcare Medicare Advantage Choice Plan 1 (PPO) (2023)Local PPO$6,700$275
5
HumanaChoice H5216-154 (PPO) (2023)Local PPO$7,550$400
4
Lasso Healthcare Growth Plus (MSA) (2023)MSA *$-$-
4
Aetna Medicare Eagle Plan (PPO) (2023)Local PPO *$6,900$-
New plan - not yet rated.
HumanaChoice H5216-142 (PPO) (2023)Local PPO$6,700$250
4
Clover Health Choice (PPO) (2023)Local PPO$7,550$0
4
Lasso Healthcare Growth (MSA) (2023)MSA *$-$-
4
Aetna Medicare Freedom Plan (PPO) (2023)Local PPO$7,550$200
New plan - not yet rated.
Aetna Medicare Preferred Premium Plan (PPO) (2023)Local PPO$6,900$195
New plan - not yet rated.
Medicare Advantage Plans by Clover Health
Clover Health Choice (PPO) (2023)Local PPO$7,550$0
4

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