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Clover Health Choice (PPO) Medicare Advantage Plan H5141-004 • 2027

CMS Rating: ☆☆☆☆☆ (5.0 out of 5 stars*)
Monthly Premium
$0.00Plus Part B premium.
Medical Deductible
$0.00
Maximum Out-of-Pocket
$9850.00In-network
Part B Giveback
Not offered
Prescription Coverage
Enhanced, $350.00 deductible
Additional Benefits
Dental, Vision, Hearing
Service Area
See List
Total Enrollment
45,687 beneficiaries
Last update:

Clover Health Choice (PPO) Introduction

Clover Health Choice is a Medicare Advantage PPO plan offered by Clover Health. It uses a Preferred Provider Organization (PPO) provider network and comes with prescription drug coverage. For the 2027 plan year it has a $0.00 monthly premium, $0.00 medical deductible, and $9850.00 in-network maximum out-of-pocket. CMS Plan ID H5141-004 identifies this plan. The 2027 Part D prescription drug deductible is $350.00.

Plan Benefits

Cost-sharing for Clover Health Choice includes out-of-pocket expenses for covered healthcare services. The following tables provide a summary of typical in-network out-of-pocket costs for plan H5141-004.

Compare 2027 plan benefits with 2026.

Office Visits

Office visit costs by plan year.
Covered Service 2027 2026
Primary care In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Specialist In-network: $15 copay
Out-of-network: $30 copay		 In-network: $10 copay
Out-of-network: $20 copay

Preventive and Wellness Services

Preventive and wellness service costs and benefits by plan year.
Covered Service 2027 2026
Annual wellness exam In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 In-network: $0 copay
Telehealth benefit In-network: $0-$15 copay In-network: $0-$10 copay
Routine chiropractic Not covered Not covered
Fitness benefits Coming soon In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Health education Not covered Not covered
Counseling services Not covered Not covered
Over-the-counter drug benefits In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Health transportation (non-emergency) Coming soon Not covered

Diagnostic, Lab, and Imaging Services

Diagnostic, laboratory, and imaging service costs by plan year.
Covered Service 2027 2026
Diagnostic radiology services In-network: $55-$225 copay
Out-of-network: $80-$325 copay		 In-network: $50-$200 copay
Out-of-network: $75-$300 copay
Lab services In-network: $0-$25 copay
Out-of-network: $50 copay		 In-network: $0-$15 copay
Out-of-network: $25 copay
Outpatient x-rays In-network: $35 copay
Out-of-network: $55 copay		 In-network: $30 copay
Out-of-network: $50 copay
Diagnostic tests and procedures In-network: $0-$225 copay
Out-of-network: $0-$325 copay		 In-network: $0-$200 copay
Out-of-network: $0-$300 copay

Emergency and Urgent Care Services

Emergency, urgent care, hospital, ambulance, and skilled nursing costs by plan year.
Covered Service 2027 2026
Emergency room care $115 copay $115 copay
Worldwide emergency care Coming soon $115 copay
Urgent care $35 copay $35 copay
Inpatient hospital care In-network:
Tier 1
$408 per day for days 1-6
$0 per day for days 7-90
$0 per stay
Out-of-network:
$560 per day for days 1-6
$0 per day for days 7-90
$0 per stay		 In-network:
Tier 1
$399 per day for days 1-6
$0 per day for days 7-90
$0 per stay
Out-of-network:
$549 per day for days 1-6
$0 per day for days 7-90
$0 per stay
Skilled Nursing Facility In-network:
Tier 1
$0 per day for days 1-20
$221 per day for days 21-100
Out-of-network:
40% per stay		 In-network:
Tier 1
$0 per day for days 1-20
$218 per day for days 21-100
Out-of-network:
40% per stay
Ground ambulance In-network: $325 copay
Out-of-network: $325 copay		 In-network: $350 copay
Out-of-network: $350 copay

Mental Health Services

Mental health therapy and inpatient psychiatric care costs by plan year.
Covered Service 2027 2026
Outpatient individual therapy In-network: $40 copay
Out-of-network: $60 copay		 In-network: $40 copay
Out-of-network: $60 copay
Outpatient group therapy In-network: $30 copay
Out-of-network: $50 copay		 In-network: $30 copay
Out-of-network: $50 copay
Inpatient psychiatric hospital care In-network:
Tier 1
$408 per day for days 1-6
$0 per day for days 7-90
$0 per stay
Out-of-network:
$560 per day for days 1-6
$0 per day for days 7-90
$0 per stay		 In-network:
Tier 1
$399 per day for days 1-6
$0 per day for days 7-90
$0 per stay
Out-of-network:
$549 per day for days 1-6
$0 per day for days 7-90
$0 per stay

Rehabilitation Services

Physical, speech, and occupational therapy costs by plan year.
Covered Service 2027 2026
Physical therapy and speech and language therapy In-network: $20 copay
Out-of-network: $30 copay		 In-network: $15 copay
Out-of-network: $25 copay
Occupational therapy In-network: $20 copay
Out-of-network: $30 copay		 In-network: $15 copay
Out-of-network: $25 copay

Medical Equipment and Supplies

Diabetes supplies, durable medical equipment, and prosthetic costs by plan year.
Covered Service 2027 2026
Diabetes supplies In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Durable medical equipment In-network: 20% coinsurance
Out-of-network: 25% coinsurance		 In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Prosthetics In-network: 20% coinsurance
Out-of-network: 25% coinsurance		 In-network: 20% coinsurance
Out-of-network: 20% coinsurance

Medicare Part B Drugs

Chemotherapy and other Medicare Part B-covered drug costs by plan year.
Covered Service 2027 2026
Chemotherapy In-network: 0%-20% coinsurance
Out-of-network: 50% coinsurance		 In-network: 0%-20% coinsurance
Out-of-network: 40% coinsurance
Other Part B drugs (Medicare-covered) In-network: 0%-20% coinsurance
Out-of-network: 50% coinsurance		 In-network: 0%-20% coinsurance
Out-of-network: 40% coinsurance

Dental Services

Preventive and comprehensive dental service costs by plan year.
Covered Service 2027 2026
Oral exam In-network: $0 copay
Out-of-network: 50% coinsurance		 In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Dental x-rays In-network: $0 copay
Out-of-network: 50% coinsurance		 In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Cleaning In-network: $0 copay
Out-of-network: 50% coinsurance		 In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Periodontics In-network: $20 copay
Out-of-network: 50% coinsurance		 In-network: $20 copay
Out-of-network: 30% coinsurance
Endodontics In-network: $20 copay
Out-of-network: 50% coinsurance		 In-network: $20 copay
Out-of-network: 30% coinsurance
Restorative services In-network: $20 copay
Out-of-network: 50% coinsurance		 In-network: $20 copay
Out-of-network: 30% coinsurance
Implant services In-network: $20 copay
Out-of-network: 50% coinsurance		 In-network: $20 copay
Out-of-network: 30% coinsurance
Orthodontics Not covered Not covered
Oral/Maxillofacial surgery In-network: $20 copay
Out-of-network: 50% coinsurance		 In-network: $20 copay
Out-of-network: 30% coinsurance

Vision Services

Routine eye exams, contact lenses, and eyewear costs by plan year.
Covered Service 2027 2026
Routine eye exam In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Contact lenses In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Eyeglass frames only Not covered Not covered
Eyeglass lenses only Not covered Not covered
Eyeglasses (frames & lenses) In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Upgrades Not covered Not covered

Hearing Services

Hearing exams, fittings, and hearing aid costs by plan year.
Covered Service 2027 2026
Hearing exam In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Fitting/evaluation In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Prescription hearing aids In-network: $499-$999 copay
Out-of-network: $5000 copay		 In-network: $499-$999 copay
Out-of-network: $5000 copay
OTC hearing aids Not covered Not covered

Additional and Special Needs Services

Additional and special needs service costs and benefits by plan year.
Covered Service 2027 2026
Adult day health services Not covered Not covered
Home-based palliative care Not covered Not covered
Personal emergency response system Coming soon Not covered
Weight management programs Not covered Not covered
Wigs for chemotherapy-related hair loss Coming soon Not covered
Alternative therapies Not covered Not covered
Massage therapy Not covered Not covered
Home/bathroom safety devices Not covered Not covered

Certain preventive services are covered 100% by Clover Health Choice as a Part B benefit.

Prescription Drug Coverage

Clover Health Choice includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.

This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.

Prescription Drug Plan Premium

The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.

Clover Health Choice (H5141-004-0) Prescription Drug Plan Premium Details
Part D Premium Component Amount
Basic Part D Premium:$0.00
Supplemental Part D Premium:$$0.00
Total Part D Premium:$0.00
Low-Income Premium Subsidy:$36.28
Low-Income Premium Subsidy Paid by CMS:$0.00
Low-Income Subsidy Premium:$0.00

For more details, visit the Social Security Extra Help program .

Prescription Drug Plan Deductible

This plan has a $350.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Clover Health starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, Clover Health Choice may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

Clover Health Choice (H5141-004-0) Pharmacy Out-of-Pocket Costs by Drug Tier
Drug Tier Retail Mail Order
Preferred Generic$0.00 copayComing soon
Generic$10.00 copayComing soon
Preferred Brand$47.00 copayComing soon
Non-Preferred Drug31% coinsuranceComing soon
Specialty Tier29% coinsuranceComing soon
*Deductible does not apply.

CMS 5-Star Performance Ratings (Contract ID: H5141)

CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.

2027 Medicare Star Ratings for Contract H5141
CMS Measure Star Rating
2027 Overall Rating ☆☆☆☆☆
Staying Healthy: Screenings, Tests, Vaccines ☆☆☆☆☆
Managing Chronic (Long Term) Conditions ☆☆☆☆☆
Member Experience with Health Plan ☆☆☆☆☆
Complaints and Changes in Plans Performance ☆☆☆☆☆
Health Plan Customer Service ☆☆☆☆☆
Drug Plan Customer Service ☆☆☆☆☆
Complaints and Changes in the Drug Plan ☆☆☆☆☆
Member Experience with the Drug Plan ☆☆☆☆☆
Drug Safety and Accuracy of Drug Pricing ☆☆☆☆☆

Contact Information for Clover Health

Website
Clover Health Plan Page
Providers
Clover Health Providers Page
Formulary
Clover Health Formulary Page
Pharmacy
Clover Health Pharmacy Page
New Member Health Plan Help
(888)466-5044
New Member Health Plan TTY
711
New Member Part D Help
(888)466-5044
New Member Part D TTY Users
711

Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.

Frequently Asked Questions

Here are some of the most frequently asked questions about this plan (click to open).

Frequently Asked Questions About Clover Health Choice (PPO)

What is the monthly premium for Clover Health Choice (PPO)?

The plan’s monthly premium is $0.00 for 2027. The Part B premium is not included.

What is the in-network MOOP for plan H5141-004?

The 2027 in-network MOOP is $9850.00. Once this limit is reached, covered in-network costs are fully covered.

What is the star rating for plan H5141-004 in 2027?

For 2027, plan H5141-004 has a CMS star rating of ★5.0 out of 5 stars.

How many beneficiaries are enrolled in this plan?

The plan has 45,687 enrolled beneficiaries according to CMS.

What is the prescription drug deductible for 2027?

For 2027, the prescription drug deductible is $350.00.

Medicare Plan Data Sources and Methodology
Primary CMS datasets used for this Medicare Advantage Plan resource.
Data Source Publisher Last Accessed
Landscape Source Files Centers for Medicare & Medicaid Services October 5, 2026
Medicare Part C & D Performance Centers for Medicare & Medicaid Services October 5, 2026
Plan Benefits Package Centers for Medicare & Medicaid Services October 5, 2026
Monthly Enrollment by Contract/Plan/State/County Centers for Medicare & Medicaid Services October 5, 2026

Data sources and methodology documentation.

Official plan information and secondary Medicare references.
Publisher Reference Last Accessed
Clover Health (official source) http://www.cloverhealth.com October 4, 2026
CMS.gov Medicare Advantage Plan Fact Sheet 25 May, 2025
Medicare.gov Joining a plan 25 May, 2025
Medicare.gov Explore your Medicare coverage options 25 May, 2025

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Provenance documentation for this data is maintained under the U.S. Core Data for Interoperability (USCDI) Provenance standard.