Peoples Health Secure Health (HMO SNP)

Plan Details: Benefits Overview

Benefits Overview (2012)

Looking for 2011 benefit information? Click here.

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)

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

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 $0
Inpatient Mental Health Care $0
Skilled Nursing Facility $0/day (days 1-100)
(100 day maximum per benefit period)
Home Health Care $0
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 (visits 1-20); 45% coinsurance/visit (visits 21+) **
Outpatient Surgery $0
Emergency Ambulance Services $0 OR $25 for each one-way trip **
Emergency Care $0 OR $50, 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.) $0
Urgently Needed Care (outside of U.S.) $0 ($5,000 combined 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 Infusion Therapy $0
Prosthetic Devices $0
Diabetes Self-Monitoring Training and Supplies $0
Diagnostic Tests, X-Rays and Lab Services $0
Visitor/Traveler Benefit Up to $5,000 in coverage per year for many routine services (in addition to your emergency and urgent care coverage outside of 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 $0/trip (up to 72 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 per year. Comprehensive services also covered, including dentures and crowns, copays apply
Health Club Membership $0 for health club membership
Health/Wellness Education/Services
(nutritional training, smoking cessation, newsletter, disease management, nurseline)
$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 (1 per year); $0 for one pair of glasses or contacts per year

PRESCRIPTION DRUG COVERAGE (PART D)
Generic Drugs Depending on income and level of extra help or state assistance: $0, $1.10 or $2.60
Preferred Brand-Name Drugs Depending on income and level of extra help or state assistance: $0, $3.30 or $6.50
Non-Preferred Brand-Name Drugs Depending on income and level of extra help or state assistance: $0, $3.30 or $6.50
Specialty Drugs Depending on income and level of extra help or state assistance: $0, $3.30 or $6.50
Mail-Order Prescription Drugs
(up to a 90-day supply)		 Depending on income and level of extra help or state assistance:
$0, $1.10 or $2.60 for a 30-day supply of generics
$0, $3.30 or $6.50 for a 30-day supply of brand-name drugs