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Peoples Health Choices 65 (HMO-POS) Southland | 2024
H1961-014-003
A Medicare Advantage plan with Part D prescription drug coverage. Available in the following parishes: Assumption, Lafourche, St. Mary, Terrebonne
$15/month
Part B Premium
Give Back
$40/quarter
Over-the-Counter
Items Allowance
$0
Primary Care
Physician Visit
$0
Primary Care
Physician Visit
$15/month
Part B Premium
GiveBack
$40/quarter
Over-the-Counter
Items Allowance
Plan Highlights | 2024
$0 Primary
Care Visits
$0
Dental Exams,
Cleanings & X-rays
$40 Over-the-Counter
Allowance per Quarter
$0
Respite Care
Services
$15/Month Part B Premium Give Back
$0
Eyeglasses
or Contacts
$0 Tier 1 & 2Â
Drug Coverage*
$0
Fitness
Benefit
*$0 Tier 2 drugs available by preferred mail-order as a 100-day supply.
Plan Benefits | 2024
The benefits below are available with this Medicare Advantage plan. For a full list of benefits, please see the Evidence of Coverage for this plan.
| Peoples Health Choices 65 (HMO-POS) Southland | Your Cost |
| Monthly Plan Premium | $0 |
| Part B Premium Give Back | $15 per month back to you |
| Doctor Visits & NurseLine | |
| Primary Care Physician Visit | $0 |
| Specialist Visit | $30 |
| Virtual Medical Visit | $0 |
| 24-Hour NurseLine | $0 |
| Preventive Care+ | |
| Pap Smears, Pelvic Exams and Mammograms | $0 |
| Prostate and Colorectal Cancer Screenings | $0 |
| Vaccinations (flu, pneumonia, hepatitis B, COVID-19)++ | $0 |
| Labs and Tests+ | |
| Lab Services | $0 |
| Diagnostic Procedures/Tests | $45 |
| X-rays | $0 |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $120 |
| Outpatient Surgery | |
| Surgery (outpatient hospital or ambulatory surgical center) | $125 |
| Inpatient Hospital Care per Admission | |
| Inpatient Deductible | $0 |
| Inpatient Stay per Day | $125 for days 1-10 $0 for days 11 and beyond |
| Home Health & Skilled Nursing Facility Care | |
| Home Health | $0 |
| Skilled Nursing Facility Care per Day (semiprivate room and board) | $0 for days 1-20 $203 for days 21-100 |
| Emergency Care, Urgent Care & Emergency Transportation^ | |
| Emergency Care | $120 |
| Urgently Needed Care | $20 |
| Emergency Ambulance Services per One-way Trip (ground or air) | $290 |
| Worldwide (out of U.S.) Emergency Care, Urgent Care and Emergency Transportation (to nearest facility) | $0 |
| Outpatient Services and Supplies | |
| Occupational, Physical or Speech Therapy Visit | $10 |
| Durable Medical Equipment - DME (wheelchairs, oxygen, etc.) | 20% coinsurance |
| Diabetes Monitoring Supplies (test strips, monitor, etc., from a DME provider or retail pharmacy) | $0 |
| Mental Health and Substance Abuse Treatment | |
| Inpatient Mental Health Care per Day | $125 for days 1-10 $0 for days 11-90 |
| Outpatient Mental Health Group or Individual Visit | $20 |
| Outpatient Substance Abuse Group or Individual Visit | $25 |
| Virtual Mental Health or Virtual Substance Abuse Treatment Visit | $0 |
| Costs listed are based on use of network providers. Authorization is required for certain services. +Office visit copay may apply. ++You will pay a $0 copay for all Part D-covered vaccines, including Shingrix, from network providers. ^Emergency care copay waived if admitted to inpatient hospital care within 24 hours for the same condition. |
All tier 1 and 2 generics are COVERED through the Part D coverage gap. Brand-name drugs have partial coverage through the gap. 100-day supplies of maintenance medications on tiers 1, 2, 3 and 4 are available at retail pharmacies and by mail order.
You will pay a maximum of $35 for each 1-month supply of Part D-covered insulin drugs through all drug payment stages, except the Catastrophic drug payment stage, where you pay $0.
You will pay a $0 copay for all Part D-covered vaccines, including Shingrix.
| Initial Coverage Stage | 30-Day Supply | 100-Day Supply |
| Tier 1 (with coverage through the gap) | $0 | $0 |
| Tier 2 (with coverage through the gap) | $10 | $0 (preferred mail order) |
| Tier 3 | $45 | $135 |
| Tier 4 | $100 | $300 |
| Tier 5 | 33% coinsurance | 30-day supply only |
| Peoples Health Choices 65 (HMO-POS) Southland | Your Cost |
| Over-the-Counter Items | |
| $40 Allowance per Quarter | $0 |
| Meals After Inpatient Hospital Stay | |
| Up to 28 Meals over 14 Days | $0 |
| Hearing Services | |
| Hearing Aids | Starting at $99 |
| Routine Hearing Exam | $0 |
| Vision Services | |
| Routine Eye Exam | $0 |
| Glasses or Contact Lenses (one pair per year - $250 allowance) | $0 |
| Dental - $2,500 Coverage Maximum | |
| Dental - Preventive (X-rays, cleanings, exams, fluoride - coverage frequency varies) | $0 |
| Dental - Comprehensive/Restorative | $0 |
| Dental – Bridges or Dentures | 50% coinsurance |
| Respite Care | |
| Members diagnosed with dementia may be eligible for a maximum of 12 respite care sessions per year from the network respite care provider | $0 |
| Fitness | |
| Health Clubs, Online Classes, Brain Health Exercises and More | $0 |
Notes:
Costs listed are based on use of network providers.
Authorization is required for certain services.
Doctor and Hospital Coverage
| Peoples Health Choices 65 (HMO-POS) Southland | Your Cost |
| Monthly Plan Premium | $0 |
| Part B Premium Give Back | $15 per month back to you |
| Doctor Visits & NurseLine | |
| Primary Care Physician Visit | $0 |
| Specialist Visit | $30 |
| Virtual Medical Visit | $0 |
| 24-Hour NurseLine | $0 |
| Preventive Care+ | |
| Pap Smears, Pelvic Exams and Mammograms | $0 |
| Prostate and Colorectal Cancer Screenings | $0 |
| Vaccinations (flu, pneumonia, hepatitis B, COVID-19)++ | $0 |
| Labs and Tests+ | |
| Lab Services | $0 |
| Diagnostic Procedures/Tests | $45 |
| X-rays | $0 |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $120 |
| Outpatient Surgery | |
| Surgery (outpatient hospital or ambulatory surgical center) | $125 |
| Inpatient Hospital Care per Admission | |
| Inpatient Deductible | $0 |
| Inpatient Stay per Day | $125 for days 1-10 $0 for days 11 and beyond |
| Home Health & Skilled Nursing Facility Care | |
| Home Health | $0 |
| Skilled Nursing Facility Care per Day (semiprivate room and board) | $0 for days 1-20 $203 for days 21-100 |
| Emergency Care, Urgent Care & Emergency Transportation^ | |
| Emergency Care | $120 |
| Urgently Needed Care | $20 |
| Emergency Ambulance Services per One-way Trip (ground or air) | $290 |
| Worldwide (out of U.S.) Emergency Care, Urgent Care and Emergency Transportation (to nearest facility) | $0 |
| Outpatient Services and Supplies | |
| Occupational, Physical or Speech Therapy Visit | $10 |
| Durable Medical Equipment - DME (wheelchairs, oxygen, etc.) | 20% coinsurance |
| Diabetes Monitoring Supplies (test strips, monitor, etc., from a DME provider or retail pharmacy) | $0 |
| Mental Health and Substance Abuse Treatment | |
| Inpatient Mental Health Care per Day | $125 for days 1-10 $0 for days 11-90 |
| Outpatient Mental Health Group or Individual Visit | $20 |
| Outpatient Substance Abuse Group or Individual Visit | $25 |
| Virtual Mental Health or Virtual Substance Abuse Treatment Visit | $0 |
| Costs listed are based on use of network providers. Authorization is required for certain services. +Office visit copay may apply. ++You will pay a $0 copay for all Part D-covered vaccines, including Shingrix, from network providers. ^Emergency care copay waived if admitted to inpatient hospital care within 24 hours for the same condition. |
Part D Prescription Drug Coverage
All tier 1 and 2 generics are COVERED through the Part D coverage gap. Brand drugs have partial coverage through the gap. 100-day supplies of maintenance medications on tiers 1, 2, 3 and 4 are available at retail pharmacies and by mail order.
You will pay a maximum of $35 for each 1-month supply of Part D-covered insulin drugs through all drug payment stages, except the Catastrophic drug payment stage, where you pay $0.
You will pay a $0 copay for all Part D covered vaccines, including Shingrix.
| Initial Coverage Stage | 30-Day Supply | 100-Day Supply |
| Tier 1 (with coverage through the gap) | $0 | $0 |
| Tier 2 (with coverage through the gap) | $10 | $0 (preferred mail order) |
| Tier 3 | $45 | $135 |
| Tier 4 | $100 | $300 |
| Tier 5 | 33% coinsurance | 30-day supply only |
Additional Benefits
| Peoples Health Choices 65 (HMO-POS) Southland | Your Cost |
| Over-the-Counter Items | |
| $40 Allowance per Quarter | $0 |
| Meals After Inpatient Hospital Stay | |
| Up to 28 Meals over 14 Days | $0 |
| Hearing Services | |
| Hearing Aids | Starting at $99 |
| Routine Hearing Exam | $0 |
| Vision Services | |
| Routine Eye Exam | $0 |
| Glasses or Contact Lenses (one pair per year - $250 allowance) | $0 |
| Dental - $2,500 Coverage Maximum | |
| Dental - Preventive (X-rays, cleanings, exams, fluoride - coverage frequency varies) | $0 |
| Dental - Comprehensive/Restorative | $0 |
| Dental – Bridges or Dentures | 50% coinsurance |
| Respite Care | |
| Members diagnosed with dementia may be eligible for a maximum of 12 respite care sessions per year from the network respite care provider | $0 |
| Fitness | |
| Health Clubs, Online Classes, Brain Health Exercises and More | $0 |
Notes:
Costs listed are based on use of network providers.
Authorization is required for certain services.
Find Doctors, Medications & More | 2024
Important Documents | 2024
Plan Overview for Peoples Health Choices 65 Southland – An overview of plan benefits
Annual Notice of Changes for Peoples Health Choices 65 Southland – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices 65 Southland – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Summary of Benefits for Peoples Health Choices 65 Southland – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services
