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Peoples Health Choices (PPO) | 2024
H4544-01
A Preferred Provider Organization plan with out-of-network coverage and Part D prescription drug coverage. Available in all Louisiana parishes.
$0
Primary Care
Physician Visit
$40/quarter
Over-the-Counter
Items Allowance
$0
Dental Exams, Cleanings
& X-rays
$0
Primary Care
Physician Visit
$0
Dental Exams,
Cleanings & X-rays
$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 Annual
Routine Hearing
Exam
$0 Fitness
Benefit
$0
Eyeglasses
or Contacts
$0 Tier 1 & 2Â
Drug Coverage*
$0 Meals
After Inpatient
Hospital Stay
*$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 (PPO) | Your Cost | Out-of-Network |
| Monthly Plan Premium | $0 | $0 |
| Doctor Visits & NurseLine | ||
| Primary Care Physician Visit | $0 | $20 |
| Specialist Visit | $35 | $55 |
| Virtual Medical Visit | $0 | Costs vary* |
| 24-Hour NurseLine | $0 | $0 (provided by NurseLine) |
| Preventive Care+ | ||
| Pap Smears, Pelvic Exams and Mammograms | $0 | 30% coinsurance |
| Prostate and Colorectal Cancer Screenings | $0 | 30% coinsurance |
| Vaccinations (flu, pneumonia, hepatitis B, COVID-19)++ | $0 | $0 |
| Labs and Tests+ | ||
| Lab Services | $0 | $0 |
| Diagnostic Procedures/Tests | $45 | 30% coinsurance |
| X-rays | $12 | $30 |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $215 | 30% coinsurance |
| Outpatient Surgery | ||
| Surgery (outpatient hospital or ambulatory surgical center) | $225 | 30% coinsurance |
| Inpatient Hospital Care per Admission | ||
| Inpatient Deductible | $0 | $0 |
| Inpatient Stay | $225 per day for days 1-7 $0 for days 8 & beyond | 30% coinsurance per stay |
| Emergency Care, Urgent Care & Emergency Transportation^ | ||
| Emergency Care | $120 | $120 |
| Urgently Needed Care | $40 | $40 |
| Emergency Ambulance Services per One-way Trip (ground or air) | $290 | $290 |
| Worldwide (out of U.S.) Emergency Care, Urgent Care and Emergency Transportation (to nearest facility) | N/A | $0 |
| Home Health & Skilled Nursing Facility Care | ||
| Home Health | $0 | 50% coinsurance |
| Skilled Nursing Facility Care per Day (semiprivate room and board) | $0 for days 1-20 $203 for days 21-100 | $225 for days 1-43 $0 for days 44-100 |
| Outpatient Services and Supplies | ||
| Occupational, Physical or Speech Therapy Visit | $20 | $55 |
| Durable Medical Equipment - DME (wheelchairs, oxygen, etc.) | 20% coinsurance | 50% coinsurance |
| Diabetes Monitoring Supplies (test strips, monitor, etc., from a DME provider or retail pharmacy) | $0 | 50% coinsurance |
| Mental Health and Substance Abuse Treatment | ||
| Inpatient Mental Health Care | $225 per day for days 1-7 $0 per day for days 8-90 | 30% coinsurance per stay |
| Outpatient Mental Health or Substance Abuse Group or Individual Visit | $15 group $25 individual | $30 group $40 individual |
| Virtual Mental Health or Virtual Substance Abuse Treatment Visit | $0 | N/A |
| *For primary care physician and specialist telehealth visits; in-office visit costs apply. +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. Authorization is required for certain services. See the Provider Directory for network lab and diagnostic providers. | ||
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 (PPO) | 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 – $750 Coverage Maximum | |
| Dental - Preventive (X-rays, cleanings, exams, fluoride - coverage frequency varies) | $0 |
| Dental - Comprehensive/Restorative | $0 |
| Dental – Bridges or Dentures | 50% coinsurance |
| 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 (PPO) | Your Cost | Out-of-Network |
| Monthly Plan Premium | $0 | $0 |
| Doctor Visits & NurseLine | ||
| Primary Care Physician Visit | $0 | $20 |
| Specialist Visit | $35 | $55 |
| Virtual Medical Visit | $0 | Costs vary* |
| 24-Hour NurseLine | $0 | $0 (provided by NurseLine) |
| Preventive Care+ | ||
| Pap Smears, Pelvic Exams and Mammograms | $0 | 30% coinsurance |
| Prostate and Colorectal Cancer Screenings | $0 | 30% coinsurance |
| Vaccinations (flu, pneumonia, hepatitis B, COVID-19)++ | $0 | $0 |
| Labs and Tests+ | ||
| Lab Services | $0 | $0 |
| Diagnostic Procedures/Tests | $45 | 30% coinsurance |
| X-rays | $12 | $30 |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $215 | 30% coinsurance |
| Outpatient Surgery | ||
| Surgery (outpatient hospital or ambulatory surgical center) | $225 | 30% coinsurance |
| Inpatient Hospital Care per Admission | ||
| Inpatient Deductible | $0 | $0 |
| Inpatient Stay | $225 per day for days 1-7 $0 for days 8 & beyond | 30% coinsurance per stay |
| Emergency Care, Urgent Care & Emergency Transportation^ | ||
| Emergency Care | $120 | $120 |
| Urgently Needed Care | $40 | $40 |
| Emergency Ambulance Services per One-way Trip (ground or air) | $290 | $290 |
| Worldwide (out of U.S.) Emergency Care, Urgent Care and Emergency Transportation (to nearest facility) | N/A | $0 |
| Home Health & Skilled Nursing Facility Care | ||
| Home Health | $0 | 50% coinsurance |
| Skilled Nursing Facility Care per Day (semiprivate room and board) | $0 for days 1-20 $203 for days 21-100 | $225 for days 1-43 $0 for days 44-100 |
| Outpatient Services and Supplies | ||
| Occupational, Physical or Speech Therapy Visit | $20 | $55 |
| Durable Medical Equipment - DME (wheelchairs, oxygen, etc.) | 20% coinsurance | 50% coinsurance |
| Diabetes Monitoring Supplies (test strips, monitor, etc., from a DME provider or retail pharmacy) | $0 | 50% coinsurance |
| Mental Health and Substance Abuse Treatment | ||
| Inpatient Mental Health Care | $225 per day for days 1-7 $0 per day for days 8-90 | 30% coinsurance per stay |
| Outpatient Mental Health or Substance Abuse Group or Individual Visit | $15 group $25 individual | $30 group $40 individual |
| Virtual Mental Health or Virtual Substance Abuse Treatment Visit | $0 | N/A |
| *For primary care physician and specialist telehealth visits; in-office visit costs apply. +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. Authorization is required for certain services. See the Provider Directory for network lab and diagnostic providers. | ||
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 (PPO) | 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 – $750 Coverage Maximum | |
| Dental - Preventive (X-rays, cleanings, exams, fluoride - coverage frequency varies) | $0 |
| Dental - Comprehensive/Restorative | $0 |
| Dental – Bridges or Dentures | 50% coinsurance |
| 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 – An overview of plan benefits
Annual Notice of Changes for Peoples Health Choices – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices – 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 – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related servicesÂ
