Peoples Health Choices Select (HMO-POS)

Plan Details: Benefits List

Benefits Overview (2012)

Looking for 2011 benefit information? Click here.

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

Benefit Overview for Peoples Health Choices Select (HMO-POS)

Benefit Description
In Network
Out of Network
Notes:
*Authorization necessary 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) Medicare-level deductible, coinsurance and copayment
Inpatient Mental Health Care $50/day (days 1-10) Medicare-level deductible, coinsurance and copayment
Skilled Nursing Facility
(100 day maximum per benefit period)		 $0/day (days 1-7);
$50/day (days 8-20);
$100/day (days 21-100)		 20% coinsurance
Home Health Care $0 20% coinsurance
Hospice Covered by Original Medicare

OUTPATIENT CARE*
Primary Care Physician (PCP) Office Visit $5 20% coinsurance
Specialist Office Visits (includes chiropractic and podiatry services) $15 20% coinsurance
Outpatient Mental Health Care / Substance Abuse Treatment $15/visit (visits 1-20)
45% coinsurance/visit
(visits 21+)		 20% coinsurance
Outpatient Surgery $50 20% coinsurance
Emergency Ambulance Services $100 for each one-way trip
Emergency Care $50, waived if admitted to inpatient hospital care ($5,000 annual combined maximum for urgently needed and emergency care outside the U.S.)
Urgently Needed Care
(within U.S.)		 $25
Urgently Needed Care
(outside of U.S.)		 $25 ($5,000 annual combined maximum for urgently needed and emergency care outside the U.S.)
Outpatient Rehabilitation Services (includes occupational, physical and speech therapy) $10 (Medicare limits apply) 20% coinsurance
(Medicare limits apply)

OUTPATIENT MEDICAL SERVICES AND SUPPLIES*
Durable Medical Equipment 20% coinsurance
Home Infusion Therapy $0 20% coinsurance
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 		20% coinsurance
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		 20% coinsurance
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)		 20% coinsurance

PREVENTIVE SERVICES*
Bone Mass Measurement $0 20% coinsurance
Colorectal Cancer Screening Exams $0 20% coinsurance
HIV Screenings $0 20% coinsurance
Immunizations $0
Mammograms $0 20% coinsurance
Pap Smears / Pelvic Exams $0 20% coinsurance
Prostate Cancer Screening Exams $0 20% coinsurance
Routine Physical Exams
(one exam/year)		 $0 20% coinsurance

TRANSPORTATION*
Transportation $5/trip (up to 12 one-way trips/year) Not covered

ADDITIONAL BENEFITS
Dental Services
(up to $1,250 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. Copays vary
Health Club Membership $0 for health club membership Not covered
Health/Wellness Education/Services
(Nutritional training, smoking cessation, newsletter, disease management, nurseline)		 $0 Not covered
Hearing Services
 $15 for each diagnostic exam
 20% coinsurance for each diagnostic hearing exam
Vision Services $15 for routine eye exam (1 per year); $0 for one pair of glasses or contacts per year Routine eye exams and eyewear not covered

PRESCRIPTION DRUG COVERAGE (PART D)
Generic Drugs $5 for a 30-day supply (covered in the coverage gap)
Preferred Brand-Name Drugs $30 for a 30-day supply
Non-Preferred Brand-Name Drugs $50 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