Peoples Health Secure Health (HMO SNP)

Plan Details: Benefits Overview

Benefits Overview

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

Benefit Overview for Peoples Health Secure Health (HMO SNP)

Benefit Description
In-Network Providers for Medicare-Covered Services

Notes:
*Authorization is required for certain services
**Cost-sharing amount may vary based on level of Louisiana Medicaid eligibility.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year.

INPATIENT CARE*
Inpatient Hospital Care $0
Inpatient Mental Health Care $0
Skilled Nursing Facility Care
(100 day maximum per benefit period)		 $0/day (days 1-100)
Hospice Covered by Original Medicare

OUTPATIENT CARE*
Primary Care Physician (PCP) Office Visit $0
Specialist Office Visit (includes chiropractic and podiatry services) $0
Outpatient Mental Health Care/Substance Abuse $0 OR $10/visit **
Outpatient Surgery $0
Emergency Ambulance Services $0 OR $25 for each one-way trip **
Emergency Care (within U.S. or outside U.S.) $0 OR $50, waived if admitted to inpatient hospital care ($5,000 combined annual maximum for emergency and urgent care outside the U.S.) **
Urgently Needed Care (within U.S.) $0
Urgently Needed Care (outside of U.S.) $0 ($5,000 combined annual maximum for emergency and urgent care services outside the U.S.)
Outpatient Rehabilitation Services (includes occupational, physical and speech therapy) $0 (Medicare limits apply)

OUTPATIENT MEDICAL SERVICES AND SUPPLIES*
Durable Medical Equipment $0
Home Health Care $0
Home Infusion Therapy $0
Prosthetic Devices $0
Diabetes Self-Monitoring Supplies $0
Diagnostic Tests, X-Rays and Lab Services $0
Visitor/Traveler Benefit Up to $5,000 in coverage per year for all plan-covered services

PREVENTIVE SERVICES*
Bone Mass Measurements $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 $0/trip (up to 48 one-way trips/year) to network providers or plan-approved locations within 30 miles of your home; additional 48 one-way trips for dialysis services, $0/trip

ADDITIONAL BENEFITS*
Dental Services
(up to $2,000 per year)		 $0 for select preventive dental services, including one oral exam and one cleaning every six months, and one set of dental X-rays per year. Comprehensive services also covered, copays apply. Dentures and fillings are covered.
Health Club Membership $0 for health club membership
Health/Wellness Education/Services
(health education, nutrition education, additional smoking cessation, nursing hotline)
$0
Hearing Services $0 for each diagnostic exam.
$25 for one hearing aid every two years ($500 maximum coverage)
Vision Services $0 for routine eye exam (one per year); $0 for one pair of glasses or contacts per year

PRESCRIPTION DRUG COVERAGE (PART D)
Preferred Generic Drugs Depending on income and level of extra help or state assistance: $0, $1.15 or $2.65
Nonpreferred Generic Drugs Depending on income and level of extra help or state assistance: $0, $1.15 or $2.65
Preferred Brand-Name Drugs Depending on income and level of extra help or state assistance: $0, $3.50 or $6.60
Non-Preferred Brand-Name Drugs Depending on income and level of extra help or state assistance: $0, $3.50 or $6.60
Specialty Drugs Depending on income and level of extra help or state assistance: $0, $3.50 or $6.60
Mail-Order Prescription Drugs
(up to a 90-day supply)		 Depending on income and level of extra help or state assistance:
$0, $1.15 or $2.65 for a 90-day supply of generics
$0, $3.50 or $6.60 for a 90-day supply of brand-name drugs