Peoples Health Choices 65 (HMO)

Plan Details: Benefits Overview

Benefits Overview (2012)

Looking for 2011 benefit information? Click here.

The following table provides an overview of the benefits offered with Peoples Health Choices 65 (HMO). For more specific information on each benefit, please refer to the Peoples Health Choices 65 (HMO) Summary of Benefits or Evidence of Coverage located on the Documents and Forms page.

Benefit Overview for Peoples Health Choices 65 (HMO)

Benefit Description
In Network
Notes:
*Authorization is required for certain services

Please note: This grid is merely an overview of plan benefits and should not be used as a replacement for the Summary of Benefits or Evidence of Coverage.

INPATIENT CARE*
Inpatient Hospital Care $50/day (days 1-10)
Inpatient Mental Health Care $50/day (days 1-10)
Skilled Nursing Facility
(100 day maximum per benefit period)		 $0/day (days 1-7);
$50/day (days 8-20);
$100/day (days 21-100)
Home Health Care $0
Hospice Covered by Original Medicare

OUTPATIENT CARE*
Primary Care Physician (PCP) Office Visit $5
Specialist Office Visit (includes chiropractic and podiatry services) $20
Outpatient Mental Health Care / Substance Abuse Treatment $20/visit (visits 1-20); 45% coinsurance/visit (visits 21+)
Outpatient Surgery $100
Emergency Ambulance Services $100 for each one-way trip
Emergency Care $65, waived if admitted to inpatient hospital care ($5,000 combined maximum for emergency and urgent care services outside the U.S.)
Urgently Needed Care (within U.S.) $25
Urgently Needed Care (outside of U.S.) $25 ($5,000 combined maximum for emergency and urgent care services outside the U.S.)
Outpatient Rehabilitation Services (includes occupational, physical and speech therapy) $10 (Medicare limits apply)

OUTPATIENT MEDICAL SERVICES AND SUPPLIES*
Durable Medical Equipment 20% coinsurance
Home Infusion Therapy $0
Prosthetic Devices 20% coinsurance
Diabetes Self-Monitoring Supplies Preferred Brands
$0 from a preferred DME vendor;
$10 for up to a 90-day supply from a network pharmacy;
20% coinsurance from other DME vendors

Non-preferred Brands
$0 from a preferred DME vendor;
20% coinsurance from other DME vendors and for up to a 90-day supply from a network pharmacy
Lab Services $0 at a freestanding lab facility;
$10 at a physician's office (in addition to office visit copayment);
20% coinsurance at an outpatient hospital facility
Diagnostic Radiology Services, X-Rays and Echocardiography $0 at an outpatient hospital facility or freestanding radiology facility;
$10 at a physician's office (in addition to office visit copayment)
Visitor/Traveler Benefit Up to $5,000 in coverage per year for many routine services (in addition to emergency and urgent care coverage outside the U.S.)

PREVENTIVE SERVICES*
Bone Mass Measurement $0
Colorectal Cancer Screening Exams $0
HIV Screenings $0
Immunizations $0
Mammograms $0
Pap Smears / Pelvic Exams $0
Prostate Cancer Screening Exams $0
Routine Physical Exams
(one exam/year)		 $0

TRANSPORTATION*
Transportation $5/trip (up to 12 one-way trips/year)

ADDITIONAL BENEFITS
Dental Services
(up to $2,000 per year)		 $0 for selected preventive dental services, including one oral exam and one cleaning every six months, and one set of dental X-rays each year. $50 deductible for comprehensive services, copays apply. Dentures and crowns are covered.
Health Club Membership $0 for health club membership
Health/Wellness Education/Services
(nutritional training, smoking cessation, newsletter, disease management, nurseline)
$0
Hearing Services (diagnostic hearing exam) $20 for each diagnostic exam
Vision Services $20 for routine eye exam (1 per year); $0 for one pair of glasses or contacts per year

PRESCRIPTION DRUG COVERAGE (PART D)
Generic Drugs $5 for a 30-day supply (covered in the coverage gap)
Preferred Brand-Name Drugs $35 for a 30-day supply (partially covered in the coverage gap)
Non-Preferred Brand-Name Drugs $55 for a 30-day supply
Specialty Drugs 20% coinsurance for a 30-day supply
Mail-Order Prescription Drugs
(up to a 90-day supply)		 Three copays for 90-day supply