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Peoples Health Patriot (PPO) | 2024
H4544-002
A Preferred Provider Organization plan with out-of-network coverage but no Part D prescription drug coverage. Available in all Louisiana parishes.
$110/month
Part B Premium
Give Back
$75/quarter
Over-the-Counter
Items Allowance
$0
Primary Care
Physician Visit
$0
Primary Care
Physician Visit
$110/month
Part B Premium
GiveBack
$75/quarter
Over-the-Counter
Items Allowance
Plan Highlights | 2024
$0 Primary
Care Visits
$0
Dental Exams,
Cleanings & X-rays
$75 Over-the-Counter
Allowance per Quarter
$0 Annual
Routine Hearing
Exam
$110/Month Part B Premium Give Back
$0
Eyeglasses
or Contacts
$0 Fitness
Benefit
$0 Meals
After Inpatient
Hospital Stay
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 Patriot (PPO) MA-only | Your Cost | Out-of-Network |
| Monthly Plan Premium | $0 | $0 |
| Part B Premium Give Back | $110 per month back to you | N/A |
| Doctor Visits & NurseLine | ||
| Primary Care Physician Visit | $0 | $20 |
| Specialist Visit | $30 | $50 |
| 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 Tests | $20 | 30% coinsurance |
| X-rays | $15 | $20 |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $225 | 30% coinsurance |
| Outpatient Surgery | ||
| Surgery (outpatient hospital or ambulatory surgical center) | $195 | 30% coinsurance |
| Inpatient Hospital Care per Admission | ||
| Inpatient Deductible | $0 | $0 |
| Inpatient Stay per Day | $195 for days 1-6 $0 for days 7 and 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) | $275 | $275 |
| 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 | $30 | $50 |
| 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 | $195 for days 1-6 $0 for days 7-90 | 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. ^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. | ||
| Peoples Health Patriot (PPO) | Your Cost |
| Over-the-Counter Items | |
| $75 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 - $200 allowance) | $0 |
| Dental – $3,000 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 Patriot (PPO) MA-only | Your Cost | Out-of-Network |
| Monthly Plan Premium | $0 | $0 |
| Part B Premium Give Back | $110 per month back to you | N/A |
| Doctor Visits & NurseLine | ||
| Primary Care Physician Visit | $0 | $20 |
| Specialist Visit | $30 | $50 |
| 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 Tests | $20 | 30% coinsurance |
| X-rays | $15 | $20 |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $225 | 30% coinsurance |
| Outpatient Surgery | ||
| Surgery (outpatient hospital or ambulatory surgical center) | $195 | 30% coinsurance |
| Inpatient Hospital Care per Admission | ||
| Inpatient Deductible | $0 | $0 |
| Inpatient Stay per Day | $195 for days 1-6 $0 for days 7 and 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) | $275 | $275 |
| 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 | $30 | $50 |
| 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 | $195 for days 1-6 $0 for days 7-90 | 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. ^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. | ||
Additional Benefits
| Peoples Health Patriot (PPO) | Your Cost |
| Over-the-Counter Items | |
| $75 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 - $200 allowance) | $0 |
| Dental – $3,000 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 Patriot – An overview of plan benefits
Annual Notice of Changes for Peoples Health Patriot – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Patriot – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Summary of Benefits for Peoples Health Patriot – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services
