Peoples Health Choices (PPO) | 2025

H4544-001

A Preferred Provider Organization plan with out-of-network coverage and Part D prescription drug coverage. Available in all Louisiana parishes.

$0
Primary Care
Provider Visit

$40/Quarter
Over-the-Counter
Items Allowance

$0
Dental Exams, Cleanings
& X-rays

Enroll OnlinE

Learn More

documents

Find Doctors

$0
Primary Care
Physician Visit

$0
Dental Exams,
Cleanings & X-rays

$40/quarter
Over-the-Counter
Items Allowance

Enroll Online

Learn More

documents

Find Doctors

Plan Highlights | 2025

$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 & 2
Drug Coverage*

$0 Meals
After Inpatient
Hospital Stay

*$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 Choices (PPO)	Your Cost	Out-of-Network
Monthly Plan Premium	$0	$0
Doctor Visits
Primary Care Provider Visit	$0	$20
Specialist Visit	$35	$60
Virtual Medical Visit	$0	Costs vary*
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	$50	30% coinsurance
X-rays	$35	$40
Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.)	$240	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 admission
Emergency Care, Urgent Care & Emergency Transportation^
Emergency Care	$125	$125
Urgently Needed Care	$55	$55
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 1-100
Outpatient Services and Supplies
Occupational, Physical or Speech Therapy Visit	$30	$60
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 1-4 $0 per day for days 5-90	30% coinsurance per admission
Outpatient Mental Health or Substance Abuse Visit	$25 individual $15 group	$40 individual $30 group
Mental Health or Substance Abuse Treatment Telehealth Individual Visit	$0	$40
*For primary care provider and specialist telehealth visits, in-office visit costs apply. +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. Authorization is required for certain services. See the Provider Directory for network lab and diagnostic providers.

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	$420 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	28% 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 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
Routine Hearing Exam	$0
Hearing Aids	$199 - $1,249 for each prescription hearing aid device $99 - $829 for each OTC hearing aid device
Vision Services
Routine Eye Exam	$0
Eyeglass Lenses (every two years)	$0 to $153
Frames or Contact Lenses (every two years)	$300 allowance
Dental - $1,500 Coverage Maximum With Platinum Dental Rider
Dental - Preventive (X-rays, cleanings, exams, fluoride - coverage frequency varies)	$0
Comprehensive/Restorative - $54 per month rider
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
Primary Care Provider Visit	$0	$20
Specialist Visit	$35	$60
Virtual Medical Visit	$0	Costs vary*
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	$50	30% coinsurance
X-rays	$35	$40
Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.)	$240	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 admission
Emergency Care, Urgent Care & Emergency Transportation^
Emergency Care	$125	$125
Urgently Needed Care	$55	$55
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 1-100
Outpatient Services and Supplies
Occupational, Physical or Speech Therapy Visit	$30	$60
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 1-4 $0 per day for days 5-90	30% coinsurance per admission
Outpatient Mental Health or Substance Abuse Visit	$25 individual $15 group	$40 individual $30 group
Mental Health or Substance Abuse Treatment Telehealth Individual Visit	$0	$40
*For primary care provider and specialist telehealth visits, in-office visit costs apply. +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. Authorization is required for certain services. See the Provider Directory for network lab and diagnostic providers.

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	$420 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	28% 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 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
Routine Hearing Exam	$0
Hearing Aids	$199 - $1,249 for each prescription hearing aid device $99 - $829 for each OTC hearing aid device
Vision Services
Routine Eye Exam	$0
Eyeglass Lenses (every two years)	$0 to $153
Frames or Contact Lenses (every two years)	$300 allowance
Dental - $1,500 Coverage Maximum With Platinum Dental Rider
Dental - Preventive (X-rays, cleanings, exams, fluoride - coverage frequency varies)	$0
Comprehensive/Restorative - $54 per month rider
Dental - Comprehensive/Restorative	$0
Dental – Bridges or Dentures	50% coinsurance
Fitness
Health Clubs, Online Classes, Brain Health Exercises and More	$0