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Peoples Health Medicare Advantage LA-0004 (HMO-POS) | 2024
H1961-020
A Medicare Advantage plan with Part D prescription drug coverage. Available in the following parishes: Ascension, East Baton Rouge, East Feliciana, Iberville, Jefferson, Livingston, Orleans, St. Charles, St. Helena, West Baton Rouge
$86/month
Part B Premium
Give Back
$40/quarter
Over-the-Counter
Items Allowance
$0
Primary Care
Physician Visit
$0
Primary Care
Physician Visit
$86/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
$86/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 Medicare Advantage LA-0004 (HMO-POS) | Your Cost |
Monthly Plan Premium | $0 |
Part B Premium Give Back | $86 per month back to you |
Doctor Visits & NurseLine | |
Primary Care Physician Visit | $0 |
Specialist Visit | $40 |
Virtual Medical Visit | $0 |
24-Hour NurseLine | $0 |
Preventive Care+ | |
Pap Smears, Pelvic Exams, Mammograms | $0 |
Prostate & Colorectal Cancer Screenings | $0 |
Vaccinations (flu, pneumonia, hepatitis B, COVID-19)++ | $0 |
Labs & Tests+ | |
Lab Services | $0 |
Diagnostic Procedures/Tests | $45 |
X-rays | $25 |
Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $225 |
Outpatient Surgery | |
Surgery (outpatient hospital or ambulatory surgical center [ASC]) | $200 ASC $250 Hospital |
Inpatient Hospital Care per Admission | |
Inpatient Deductible | $0 |
Inpatient Stay per Day | $275 for days 1-6 $0 for days 7 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 | $40 |
Emergency Ambulance Services per One-way Trip (ground or air) | $275 |
Worldwide (out of U.S.) Emergency Care, Urgent Care and Emergency Transportation (to nearest facility) | $0 |
Outpatient Services & Supplies | |
Occupational, Physical or Speech Therapy Visit | $40 |
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 & Substance Abuse Treatment | |
Inpatient Mental Health Care per Day | $275 for days 1-6 $0 for days 7-90 |
Outpatient Mental Health Visit | $15 group $25 individual |
Outpatient Substance Abuse Treatment Visit | $15 group $25 individual |
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 |
Medicare Advantage LA-0004 (HMO-POS) | Your Cost |
Over-the-Counter Items | |
$40 Allowance per Quarter | $0 |
Meals After Inpatient Hospital Stay | |
Up to 28 Meals Over 14 Days | $0 |
Vision Services | |
Routine Eye Exam | $0 |
Glasses or Contact Lenses (one pair per year - $150 allowance) | $0 |
Hearing Services | |
Hearing Aids | Starting at $99 |
Routine Hearing Exam | $0 |
Dental - $1,000 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 Medicare Advantage LA-0004 (HMO-POS) | Your Cost |
Monthly Plan Premium | $0 |
Part B Premium Give Back | $86 per month back to you |
Doctor Visits & NurseLine | |
Primary Care Physician Visit | $0 |
Specialist Visit | $40 |
Virtual Medical Visit | $0 |
24-Hour NurseLine | $0 |
Preventive Care+ | |
Pap Smears, Pelvic Exams, Mammograms | $0 |
Prostate & Colorectal Cancer Screenings | $0 |
Vaccinations (flu, pneumonia, hepatitis B, COVID-19)++ | $0 |
Labs & Tests+ | |
Lab Services | $0 |
Diagnostic Procedures/Tests | $45 |
X-rays | $25 |
Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $225 |
Outpatient Surgery | |
Surgery (outpatient hospital or ambulatory surgical center [ASC]) | $200 ASC $250 Hospital |
Inpatient Hospital Care per Admission | |
Inpatient Deductible | $0 |
Inpatient Stay per Day | $275 for days 1-6 $0 for days 7 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 | $40 |
Emergency Ambulance Services per One-way Trip (ground or air) | $275 |
Worldwide (out of U.S.) Emergency Care, Urgent Care and Emergency Transportation (to nearest facility) | $0 |
Outpatient Services & Supplies | |
Occupational, Physical or Speech Therapy Visit | $40 |
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 & Substance Abuse Treatment | |
Inpatient Mental Health Care per Day | $275 for days 1-6 $0 for days 7-90 |
Outpatient Mental Health Visit | $15 group $25 individual |
Outpatient Substance Abuse Treatment Visit | $15 group $25 individual |
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
Medicare Advantage LA-0004 (HMO-POS) | Your Cost |
Over-the-Counter Items | |
$40 Allowance per Quarter | $0 |
Meals After Inpatient Hospital Stay | |
Up to 28 Meals Over 14 Days | $0 |
Vision Services | |
Routine Eye Exam | $0 |
Glasses or Contact Lenses (one pair per year - $150 allowance) | $0 |
Hearing Services | |
Hearing Aids | Starting at $99 |
Routine Hearing Exam | $0 |
Dental - $1,000 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 Medicare Advantage LA-0004 – An overview of plan benefits
Evidence of Coverage for Peoples Health Medicare Advantage LA-0004 – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Summary of Benefits for Peoples Health Medicare Advantage LA-0004 – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services