Peoples Health Choices 65 (HMO) Northshore
St. Tammany, Tangipahoa, Washington
$0
Monthly
Plan
Premium
The Peoples Health Choices 65 (HMO) Northshore plan is a Medicare Advantage Prescription Drug plan with a Part B premium Give Back (we pay a portion of your monthly Medicare Part B premium for you) and a quarterly allowance for over-the-counter health & wellness items.
The Peoples Health Choices 65 (HMO) Northshore plan is a Medicare Advantage Prescription Drug plan with a Part B premium Give Back (we pay a portion of your monthly Medicare Part B premium for you) and a quarterly allowance for over-the-counter health & wellness items.
Plan Highlights
Plan Highlights
Coordinated care through our extensive network of providers. This plan features health and drug coverage, over-the-counter health & wellness items, plus a monthly Give Back – we pay part of your Medicare Part B premium for you.
$0 PCP
$40/Quarter Over-the-Counter Items
$10 Give Back
$0 Tier 1 Drugs
$0 Dental Exams & Cleanings
$0 Eyeglasses or contacts
$0 Fitness Club Membership
$0 Hearing Aids
Plan Benefits
The benefits below are available with this Medicare Advantage plan. To see a full list of benefits, please see the Evidence of Coverage for this plan.
Peoples Health Choices 65 (HMO)
Northshore Your Cost Monthly Plan Premium $0 Part B Premium Give Back $10 per month back to you Doctor Visits & NurseLine Primary Care Physician Visit $0 Specialist Visit $50 Virtual Medical Visit $0 24-Hour NurseLine $0 Preventive Care+ Pap Smears, Pelvic Exams, Mammograms $0 Prostate and Colorectal Cancer Screenings $0 Vaccinations (flu, pneumonia, hepatitis B) $0 Labs & Tests*+ Lab Services (at contracted lab provider) $0 Diagnostic Tests (at contracted outpatient facility) $0 X-rays (at contracted radiology facility) $0 Advanced Imaging (MRI, MRA, CT, PET scans, etc.) $175 Outpatient Surgery Surgery (outpatient hospital or ambulatory surgical center) $200 Inpatient Hospital Care per admission Inpatient Deductible $0 Inpatient Stay per day, for days 1 - 8 $215 Inpatient Stay for days 9 and beyond $0 Emergency Care, Urgent Care & Emergency Transportation Emergency Care $90 Urgent Care $50 Emergency Ambulance $250 Worldwide Emergency Care, Urgent Care and Emergency Transportation (to nearest facility) $0 Home Health & Skilled Nursing Facility Care Home Health $0 Skilled Nursing Facility Care $0 for days 1-20
$165 per day, for days 21-100 Outpatient Services & Supplies Occupational, Physical or Speech Therapy Visit $20 Durable Medical Equipment - DME (wheelchairs, oxygen, etc.) 20% coinsurance Diabetes Monitoring Supplies (test strips, monitor, etc.,from a preferred DME provider) $0 Mental Health & Substance Abuse Treatment Inpatient Mental Health $215 per day, days 1-8
$0 for days 9-90 Outpatient Mental Health Group or Individual Visit $40 Outpatient Substance Abuse Group or Individual Visit $50 Virtual Mental Health or Substance Abuse Treatment Visit $0
| Peoples Health Choices 65 (HMO) Northshore | Your Cost |
| Monthly Plan Premium | $0 |
| Part B Premium Give Back | $10 per month back to you |
| Doctor Visits & NurseLine | |
| Primary Care Physician Visit | $0 |
| Specialist Visit | $50 |
| Virtual Medical Visit | $0 |
| 24-Hour NurseLine | $0 |
| Preventive Care+ | |
| Pap Smears, Pelvic Exams, Mammograms | $0 |
| Prostate and Colorectal Cancer Screenings | $0 |
| Vaccinations (flu, pneumonia, hepatitis B) | $0 |
| Labs & Tests*+ | |
| Lab Services (at contracted lab provider) | $0 |
| Diagnostic Tests (at contracted outpatient facility) | $0 |
| X-rays (at contracted radiology facility) | $0 |
| Advanced Imaging (MRI, MRA, CT, PET scans, etc.) | $175 |
| Outpatient Surgery | |
| Surgery (outpatient hospital or ambulatory surgical center) | $200 |
| Inpatient Hospital Care per admission | |
| Inpatient Deductible | $0 |
| Inpatient Stay per day, for days 1 - 8 | $215 |
| Inpatient Stay for days 9 and beyond | $0 |
| Emergency Care, Urgent Care & Emergency Transportation | |
| Emergency Care | $90 |
| Urgent Care | $50 |
| Emergency Ambulance | $250 |
| Worldwide Emergency Care, Urgent Care and Emergency Transportation (to nearest facility) | $0 |
| Home Health & Skilled Nursing Facility Care | |
| Home Health | $0 |
| Skilled Nursing Facility Care | $0 for days 1-20 $165 per day, for days 21-100 |
| Outpatient Services & Supplies | |
| Occupational, Physical or Speech Therapy Visit | $20 |
| Durable Medical Equipment - DME (wheelchairs, oxygen, etc.) | 20% coinsurance |
| Diabetes Monitoring Supplies (test strips, monitor, etc.,from a preferred DME provider) | $0 |
| Mental Health & Substance Abuse Treatment | |
| Inpatient Mental Health | $215 per day, days 1-8 $0 for days 9-90 |
| Outpatient Mental Health Group or Individual Visit | $40 |
| Outpatient Substance Abuse Group or Individual Visit | $50 |
| Virtual Mental Health or Substance Abuse Treatment Visit | $0 |
Notes:
Costs listed are based on use of network providers.
Authorization is required for certain services.
*See the Provider Directory for network lab and diagnostic providers. Lab services, diagnostic tests and X-rays at a doctor’s office or outpatient hospital may have higher out-of-pocket costs.
+Office visit copay may apply.
♦Emergency care copay waived if admitted to inpatient hospital care within 24 hours for the same condition.
All tier 1 and 2 generics are COVERED through the Part D coverage gap. Brand drugs have partial coverage through the gap. 90-day supplies of maintenance medications on tiers 1, 2, 3 and 4 are available at retail pharmacies and by mail order.
| Initial Coverage Stage | 30-Day Supply | 90-Day Supply |
| Tier 1* | $0 | $0 |
| Tier 2* | $10 | $0 (preferred mail order) |
| Tier 3 | $45 | $135 |
| Tier 4 | $100 | $300 |
| Tier 5 | 33% coinsurance | 30-day supply only |
*With coverage through the gap
| Peoples Health Choices 65 (HMO) Northshore | Your Cost |
| Over-the-Counter Health and Wellness Items | |
| $40 Allowance per quarter | $0 |
| Meals After Inpatient Hospital Stay | |
| 2 meals per day for up to 5 days | $0 |
| Vision Services | |
| Routine Eye Exam | $40 |
| Eyeglasses or Contact Lenses (one pair per year) | $0 |
| Hearing Services* | |
| Hearing Aids (up to $500 per ear) | $0 |
| Respite Care | |
| Members diagnosed with dementia may be eligible for a maximum of 12 respite care sessions per year from the network respite care provider | $0 |
| Dental - $2,000 Coverage Maximum | |
| Dental - Preventive (1 set of X-rays and 2 exams and cleanings per year) | $0 |
| Dental - Comprehensive (fillings, dentures, etc.) | Copays vary; $50 deductible applies |
| Fitness | |
| Fitness Center Membership | $0 |
Notes:
*Hearing aid services provided through the TruHearing network.
Costs listed are based on use of network providers.
Authorization is required for certain services.
Plan Benefits
Doctor and Hospital Coverage
| Peoples Health Choices 65 (HMO) Northshore | Your Cost |
| Monthly Plan Premium | $0 |
| Part B Premium Give Back | $10 per month back to you |
| Doctor Visits & NurseLine | |
| Primary Care Physician Visit | $0 |
| Specialist Visit | $50 |
| Virtual Medical Visit | $0 |
| 24-Hour NurseLine | $0 |
| Preventive Care+ | |
| Pap Smears, Pelvic Exams, Mammograms | $0 |
| Prostate and Colorectal Cancer Screenings | $0 |
| Vaccinations (flu, pneumonia, hepatitis B) | $0 |
| Labs & Tests*+ | |
| Lab Services (at contracted lab provider) | $0 |
| Diagnostic Tests (at contracted outpatient facility) | $0 |
| X-rays (at contracted radiology facility) | $0 |
| Advanced Imaging (MRI, MRA, CT, PET scans, etc.) | $175 |
| Outpatient Surgery | |
| Surgery (outpatient hospital or ambulatory surgical center) | $200 |
| Inpatient Hospital Care per admission | |
| Inpatient Deductible | $0 |
| Inpatient Stay per day, for days 1 - 8 | $215 |
| Inpatient Stay for days 9 and beyond | $0 |
| Emergency Care, Urgent Care & Emergency Transportation | |
| Emergency Care | $90 |
| Urgent Care | $50 |
| Emergency Ambulance | $250 |
| Worldwide Emergency Care, Urgent Care and Emergency Transportation (to nearest facility) | $0 |
| Home Health & Skilled Nursing Facility Care | |
| Home Health | $0 |
| Skilled Nursing Facility Care | $0 for days 1-20 $165 per day, for days 21-100 |
| Outpatient Services & Supplies | |
| Occupational, Physical or Speech Therapy Visit | $20 |
| Durable Medical Equipment - DME (wheelchairs, oxygen, etc.) | 20% coinsurance |
| Diabetes Monitoring Supplies (test strips, monitor, etc.,from a preferred DME provider) | $0 |
| Mental Health & Substance Abuse Treatment | |
| Inpatient Mental Health | $215 per day, days 1-8 $0 for days 9-90 |
| Outpatient Mental Health Group or Individual Visit | $40 |
| Outpatient Substance Abuse Group or Individual Visit | $50 |
| Virtual Mental Health or Substance Abuse Treatment Visit | $0 |
Notes:
Costs listed are based on use of network providers.
Authorization is required for certain services.
*See the Provider Directory for network lab and diagnostic providers. Lab services, diagnostic tests and X-rays at a doctor’s office or outpatient hospital may have higher out-of-pocket costs.
+Office visit copay may apply.
♦Emergency care copay waived if admitted to inpatient hospital care within 24 hours for the same condition.
Part D Prescription Drug Coverage
All tier 1 and 2 generics are COVERED through the Part D coverage gap. Brand drugs have partial coverage through the gap. 90-day supplies of maintenance medications on tiers 1, 2, 3 and 4 are available at retail pharmacies and by mail order.
| Initial Coverage Stage | 30-Day Supply | 90-Day Supply |
| Tier 1* | $0 | $0 |
| Tier 2* | $10 | $0 (preferred mail order) |
| Tier 3 | $45 | $135 |
| Tier 4 | $100 | $300 |
| Tier 5 | 33% coinsurance | 30-day supply only |
*With coverage through the gap
Additional Benefits
| Peoples Health Choices 65 (HMO) Northshore | Your Cost |
| Over-the-Counter Health and Wellness Items | |
| $40 Allowance per quarter | $0 |
| Meals After Inpatient Hospital Stay | |
| 2 meals per day for up to 5 days | $0 |
| Vision Services | |
| Routine Eye Exam | $40 |
| Eyeglasses or Contact Lenses (one pair per year) | $0 |
| Hearing Services* | |
| Hearing Aids (up to $500 per ear) | $0 |
| Respite Care | |
| Members diagnosed with dementia may be eligible for a maximum of 12 respite care sessions per year from the network respite care provider | $0 |
| Dental - $2,000 Coverage Maximum | |
| Dental - Preventive (1 set of X-rays and 2 exams and cleanings per year) | $0 |
| Dental - Comprehensive (fillings, dentures, etc.) | Copays vary; $50 deductible applies |
| Fitness | |
| Fitness Center Membership | $0 |
Notes:
Costs listed are based on use of network providers. Authorization is required for certain services.
Find Doctors, Search Medications and More
Important Documents
Plan Overview for Peoples Health Choices 65 Northshore – An overview of plan benefits
Annual Notice of Changes for Peoples Health Choices 65 Northshore – A summary of plan benefit changes compared to the previ ous year and other important plan details
Evidence of Coverage for Peoples Health Choices 65 Northshore – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Summary of Benefits for Peoples Health Choices 65 Northshore – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services for your plan
How to Enroll
HOW DO I ENROLL ONLINE?
Enrolling only takes 20 minutes.
HOW DO I ENROLL BY PHONE?
Call toll-free at 1-866-687-7335, seven days a week, from 8 a.m. to 8 p.m.
TTY users may call 711.
A plan representative will help you.
HOW DO I ENROLL BY APPOINTMENT?
Call us toll-free at 1-866-687-7335, 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.
HOW DO I ENROLL BY MAIL?
Write to us and request an enrollment packet. The address is:
Peoples Health Choices 65 Northshore Enrollment Packet Request
Three Lakeway Center
3838 N. Causeway Blvd. Suite 2200
Metairie, LA 70002
Extra Help
Peoples Health Choices 65 Northshore Monthly Plan Premium for People Who Get Extra Help From Medicare to Help Pay Their Prescription Drug Costs
If you get Extra Help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get Extra Help from Medicare. The amount of Extra Help you get will determine your total monthly plan premium as a member of our plan.
Peoples Health Choices 65 Northshore’s premium includes coverage for both medical services and prescription drug coverage.
SEE IF YOU QUALIFY FOR EXTRA HELP
If you aren’t getting Extra Help, you can see if you qualify by calling:
- Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week (TTY users call 1-877-486-2048)
- Louisiana Medicaid at 1-888-342-6207, (TTY users call 1-800-220-5404), or
- Social Security Administration at 1-800-772-1213, Monday through Friday, from 7 a.m. to 7 p.m. (TTY users call 1-800-325-0778)
EXTRA HELP MONTHLY PLAN PREMIUM TABLE
This table shows you what your monthly plan premium will be if you get Extra Help.
| YOUR LEVEL OF EXTRA HELP | MONTHLY PREMIUM FOR PEOPLES HEALTH CHOICES 65 (HMO) NORTHSHORE* |
| 100% | $0 |
| 75% | $0 |
| 50% | $0 |
| 25% | $0 |
*This does not include any Medicare Part B premium you may have to pay.