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Peoples Health Patriot (PPO) | 2025
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
$50/Quarter
Over-the-Counter
Items Allowance
$0
Primary Care
Provider Visit
$0
Primary Care
Physician Visit
$110/month
Part B Premium
GiveBack
$50/quarter
Over-the-Counter
Items Allowance
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Plan Highlights | 2025
$0 Primary
Care Visits
$0
Dental Exams,
Cleanings & X-rays
$50 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
*$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 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 | ||
| Primary Care Provider Visit | $0 | $20 |
| Specialist Visit | $55 | $70 |
| 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 Tests | $50 | 30% coinsurance |
| X-rays | $25 | $30 |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $250 | 30% coinsurance |
| Outpatient Surgery | ||
| Surgery (outpatient hospital or ambulatory surgical center) | $295 | 30% coinsurance |
| Inpatient Hospital Care per Admission | ||
| Inpatient Deductible | $0 | $0 |
| Inpatient Stay per Day | $295 for days 1-6 $0 for days 7 and 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) | $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 1-100 |
| Outpatient Services and Supplies | ||
| Occupational, Physical or Speech Therapy Visit | $45 occcupational $50 physical/speech | $70 |
| 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 | $295 for days 1-6 $0 for days 7-90 | 30% coinsurance per stay |
| Outpatient Mental Health or Substance Abuse Visit | $15 group $25 individual | $30 group $40 individual |
| 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. ^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 | |
| $50 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) | $250 allowance |
| Dental – $2,000 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 | ||
| Primary Care Provider Visit | $0 | $20 |
| Specialist Visit | $55 | $70 |
| 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 Tests | $50 | 30% coinsurance |
| X-rays | $25 | $30 |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $250 | 30% coinsurance |
| Outpatient Surgery | ||
| Surgery (outpatient hospital or ambulatory surgical center) | $295 | 30% coinsurance |
| Inpatient Hospital Care per Admission | ||
| Inpatient Deductible | $0 | $0 |
| Inpatient Stay per Day | $295 for days 1-6 $0 for days 7 and 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) | $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 1-100 |
| Outpatient Services and Supplies | ||
| Occupational, Physical or Speech Therapy Visit | $45 occcupational $50 physical/speech | $70 |
| 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 | $295 for days 1-6 $0 for days 7-90 | 30% coinsurance per stay |
| Outpatient Mental Health or Substance Abuse Visit | $15 group $25 individual | $30 group $40 individual |
| 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. ^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 | |
| $50 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) | $250 allowance |
| Dental – $2,000 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 | 2025
Important Documents | 2025
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
How to Enroll | 2025
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.