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Peoples Health Medicare Advantage Giveback LA-4 (HMO-POS) | 2025
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
$106/Month
Part B Premium
Give Back
$40/Quarter
Over-the-Counter
Items Allowance
$0
Primary Care
Provider Visit
$0
Primary Care
Physician Visit
$106/month
Part B Premium
GiveBack
$40/quarter
Over-the-Counter
Items Allowance
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Plan Highlights | 2025
$0 Primary
Care Visits
$0
Dental Exams,
Cleanings & X-rays
$40 Over-the-Counter
Allowance per Quarter
$0
Respite Care
Services
$106/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.
**$0 Standard Eyeglass Lenses; Allowance Amount for Eyeglass Frames or Contacts
Plan Benefits | 2025
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 Giveback LA-4 (HMO-POS) | Your Cost |
| Monthly Plan Premium | $0 |
| Part B Premium Give Back | $106 per month back to you |
| Doctor Visits | |
| Primary Care Provider Visit | $0 |
| Specialist Visit | $40 |
| Virtual Medical Visit | $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.) | $250 |
| Outpatient Surgery | |
| Surgery (outpatient hospital or ambulatory surgical center [ASC]) | $350 |
| Inpatient Hospital Care per Admission | |
| Inpatient Deductible | $0 |
| Inpatient Stay per Day | $350 for days 1-7 $0 for days 8 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 | $125 |
| Urgently Needed Care | $55 |
| 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 occupational $45 physical/speech |
| 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 | $350 for days 1-6 $0 for days 7-90 |
| Outpatient Mental Health Visit | $25 individual $15 group |
| Outpatient Substance Abuse Treatment Visit | $25 individual $15 group |
| Mental Health or Substance Abuse Treatment Telehealth Individual 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 most 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. |
100-day supplies of maintenance medications on tiers 1, 2 and 3 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 coverage stage, where you pay $0.
You will pay a $0 copay for most Part D-covered vaccines, including Shingrix.
| Deductible Stage | $340 deductible for tiers 3-5 | |
| Initial Coverage Stage | 30-Day Supply | 100-Day Supply |
| Tier 1 | $0 | $0 |
| Tier 2 | $10 | $0 (preferred mail order) |
| Tier 3 | $47 | $141 |
| Tier 4 | $100 | 30-day supply only |
| Tier 5 | 29% coinsurance | 30-day supply only |
The Medicare Prescription Payment Plan: Starting Jan. 1, 2025, if you spend more than $2,000 for covered Part D prescription drugs each year, you may want to participate in the Medicare Prescription Payment Plan. This payment plan spreads your out-of-pocket prescription drug costs over the remainder of the calendar year. Learn more about the Medicare Prescription Payment Plan.
| Peoples Health Medicare Advantage Giveback LA-4 (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 |
| Eyeglass Lenses (every two years) | $0 to $153 |
| Frames or Contact Lenses (every two years) | $200 allowance |
| Hearing Services | |
| Routine Hearing Exam | $0 |
| Hearing Aids | $199 - $1,249 for each prescription hearing aid device $99 - $829 for each OTC hearing aid device |
| Dental - $1,500 Coverage Maximum With Platinum Dental Rider | |
| Dental - Preventive (X-rays, cleanings, exams, fluoride - coverage frequency varies) | $0 |
| Platinum Dental Rider for Comprehensive Services - $54/month rider | |
| 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 Giveback LA-4 (HMO-POS) | Your Cost |
| Monthly Plan Premium | $0 |
| Part B Premium Give Back | $106 per month back to you |
| Doctor Visits | |
| Primary Care Provider Visit | $0 |
| Specialist Visit | $40 |
| Virtual Medical Visit | $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.) | $250 |
| Outpatient Surgery | |
| Surgery (outpatient hospital or ambulatory surgical center [ASC]) | $350 |
| Inpatient Hospital Care per Admission | |
| Inpatient Deductible | $0 |
| Inpatient Stay per Day | $350 for days 1-7 $0 for days 8 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 | $125 |
| Urgently Needed Care | $55 |
| 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 occupational $45 physical/speech |
| 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 | $350 for days 1-6 $0 for days 7-90 |
| Outpatient Mental Health Visit | $25 individual $15 group |
| Outpatient Substance Abuse Treatment Visit | $25 individual $15 group |
| Mental Health or Substance Abuse Treatment Telehealth Individual 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 most 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
100-day supplies of maintenance medications on tiers 1, 2 and 3 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 coverage stage, where you pay $0.
You will pay a $0 copay for most Part D-covered vaccines, including Shingrix.
| Deductible Stage | $340 deductible for tiers 3-5 | |
| Initial Coverage Stage | 30-Day Supply | 100-Day Supply |
| Tier 1 | $0 | $0 |
| Tier 2 | $10 | $0 (preferred mail order) |
| Tier 3 | $47 | $141 |
| Tier 4 | $100 | 30-day supply only |
| Tier 5 | 29% coinsurance | 30-day supply only |
The Medicare Prescription Payment Plan: Starting Jan. 1, 2025, if you spend more than $2,000 for covered Part D prescription drugs each year, you may want to participate in the Medicare Prescription Payment Plan. This payment plan spreads your out-of-pocket prescription drug costs over the remainder of the calendar year. Learn more about the Medicare Prescription Payment Plan.
Additional Benefits
| Peoples Health Medicare Advantage Giveback LA-4 (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 |
| Eyeglass Lenses (every two years) | $0 to $153 |
| Frames or Contact Lenses (every two years) | $200 allowance |
| Hearing Services | |
| Routine Hearing Exam | $0 |
| Hearing Aids | $199 - $1,249 for each prescription hearing aid device $99 - $829 for each OTC hearing aid device |
| Dental - $1,500 Coverage Maximum With Platinum Dental Rider | |
| Dental - Preventive (X-rays, cleanings, exams, fluoride - coverage frequency varies) | $0 |
| Platinum Dental Rider for Comprehensive Services - $54/month rider | |
| 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 | 2025
Important Documents | 2025
Plan Overview for Peoples Health Medicare Advantage Giveback LA-4 (HMO-POS) – An overview of plan benefits
Annual Notice of Changes for Peoples Health Medicare Advantage Giveback LA-4 (HMO-POS) – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Medicare Advantage Giveback LA-4 (HMO-POS) – 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 Giveback LA-4 (HMO-POS) – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services
How to Enroll
Online
Enrolling online only takes about 20 minutes. You’ll need your red, white and blue Medicare card to complete the online application.
By Phone
Call toll-free at
1-800-978-9765, seven days a week, from 8 a.m. to 8 p.m.
TTY users may call 711.
A plan representative will help you. You can also request an enrollment packet.
By Appointment
Call toll-free at
1-800-978-9765, seven days a week, from 8 a.m. to 8 p.m.
TTY users may call 711.
A sales representative will schedule an appointment
with you.