Peoples Health Choices Gold (HMO)
$0
Monthly
Plan
Premium
The Peoples Health Choices Gold plan is a Medicare Advantage Prescription Drug plan with a $40 per quarter allowance for over-the-counter health & wellness items.
The Peoples Health Choices Gold plan is a Medicare Advantage Prescription Drug plan with a $40 per quarter allowance for over-the-counter health & wellness items.
Available in the following parishes
• Acadia
• Bossier
• Caddo
• Calcasieu
• Cameron
• Evangeline
• Iberia
• Lafayette
• Ouachita
• St. Landry
• St. Martin
• Vermilion
Available in the Following Parishes
Acadia, Bossier, Caddo, Calcasieu, Cameron, Evangeline, Iberia, Lafayette, Ouachita, St. Landry, St. Martin, Vermilion.
Plan Highlights
Plan Highlights
This HMO plan includes in-network coverage and an allowance for over-the-counter items.
$0 PCP
$40/Quarter Over-the-Counter Items
$0 Meals After Inpatient Hospital Stay
$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 Gold (HMO) | Your Cost |
| Monthly Plan Premium | $0 |
| Doctor Visits | |
| Primary Care Physician Visit | $0 |
| Specialist Visit | $35 |
| Virtual Medical Visit | $0 |
| 24-Hour NurseLine | $0 |
| Preventive Care+ | |
| Pap Smears, Pelvic Exams, Mammograms | $0 |
| Prostate & Colorectal Cancer Screenings | $0 |
| Vaccinations (flu, pneumonia, hepatitis B) | $0 |
| Labs & Tests*+ | |
| Lab Services | $0 at provider contracted to provide lab services (may include lab provider or outpatient hospital) |
| Diagnostic Tests | $10 at outpatient facility |
| X-rays | $10 at physician’s office |
| Advanced Imaging | $120 |
| Outpatient Surgery (Outpatient Hospital or Ambulatory Surgical Center) | |
| Outpatient Surgery | $250 |
| Inpatient Hospital Care per admission | |
| Inpatient Deductible | $0 |
| Inpatient Stay | $195 per day, for days 1-10 |
| Inpatient Stay | $0 for days 11 and beyond |
| Emergency Care, Urgent Care & Emergency Transportation♦ | |
| Emergency Care | $90 |
| Urgent Care | $40 |
| 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 Care | $195 per day, for days 1-9 $0 for days 10-90 |
| Outpatient Mental Health or Substance Abuse Group or Individual Visit | $40 |
| 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 other locations 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.Â
All tier 1 and 2 generics are COVERED through the Part D coverage gap. Brand-name drugs have partial coverage through the gap. 90-day supplies of maintenance medications for drugs on tiers 1-4 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 |
| Peoples Health Choices Gold (HMO) | 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 | $35 (one per year) |
| Glasses or Contact Lenses | $0 (one pair per year) |
| 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 - $1,250 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 Gold (HMO) | Your Cost |
| Monthly Plan Premium | $0 |
| Doctor Visits | |
| Primary Care Physician Visit | $0 |
| Specialist Visit | $35 |
| Virtual Medical Visit | $0 |
| 24-Hour NurseLine | $0 |
| Preventive Care+ | |
| Pap Smears, Pelvic Exams, Mammograms | $0 |
| Prostate & Colorectal Cancer Screenings | $0 |
| Vaccinations (flu, pneumonia, hepatitis B) | $0 |
| Labs & Tests*+ | |
| Lab Services | $0 at provider contracted to provide lab services (may include lab provider or outpatient hospital) |
| Diagnostic Tests | $10 at outpatient facility |
| X-rays | $10 at physician’s office |
| Advanced Imaging | $120 |
| Outpatient Surgery (Outpatient Hospital or Ambulatory Surgical Center) | |
| Outpatient Surgery | $250 |
| Inpatient Hospital Care per admission | |
| Inpatient Deductible | $0 |
| Inpatient Stay | $195 per day, for days 1-10 |
| Inpatient Stay | $0 for days 11 and beyond |
| Emergency Care, Urgent Care & Emergency Transportation♦ | |
| Emergency Care | $90 |
| Urgent Care | $40 |
| 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 Care | $195 per day, for days 1-9 $0 for days 10-90 |
| Outpatient Mental Health or Substance Abuse Group or Individual Visit | $40 |
| 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 other locations 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 for drugs on tiers 1-4 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 Gold (HMO) | 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 | $35 (one per year) |
| Glasses or Contact Lenses | $0 (one pair per year) |
| 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 - $1,250 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.
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Important Documents
Plan Overview for Peoples Health Choices Gold – An overview of plan benefits
Annual Notice of Changes for Peoples Health Choices Gold  – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices Gold – 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 Gold – 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 1-800-978-9765, 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 at1-800-978-9765, 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 Gold Enrollment Packet Request
Three Lakeway Center
3838 N. Causeway Blvd.
Suite 2500
Metairie, LA 70002
Extra Help
Peoples Health Choices Gold 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 Gold’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 GOLD (HMO)* |
| 100% | $0 |
| 75% | $0 |
| 50% | $0 |
| 25% | $0 |
*This does not include any Medicare Part B premium you may have to pay.