Peoples Health Choices 65 (HMO-POS) Southland | 2024
H1961-014-003
A Medicare Advantage plan with Part D prescription drug coverage. Available in the following parishes:
Assumption, Lafourche, St. Mary, Terrebonne
$15/month
Part B Premium
Give Back
$40/quarter
Over-the-Counter
Items Allowance
$0
Primary Care
Physician Visit
$0
Primary Care
Physician Visit
$15/month
Part B Premium
GiveBack
$40/quarter
Over-the-Counter
Items Allowance
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Plan Highlights
$0 Primary
Care Visits
$0
Dental Exams,
Cleanings & X-rays
$40 Over-the-Counter
Allowance per Quarter
$0
Respite Care
Services
$15/Month Part B Premium Give Back
$0
Eyeglasses
or Contacts
$0 Tier 1 & 2Â
Drug Coverage*
$0
Fitness
Benefit
*$0 Tier 2 drugs available by preferred mail-order as a 100-day supply.
Plan Benefits
The benefits below are available with this Medicare Advantage plan. For a full list of benefits, please see the Evidence of Coverage for this plan.
| Peoples Health Choices 65 (HMO-POS) Southland | Your Cost |
| Monthly Plan Premium | $0 |
| Part B Premium Give Back | $15 per month back to you |
| Doctor Visits & NurseLine | |
| Primary Care Physician Visit | $0 |
| Specialist Visit | $30 |
| Virtual Medical Visit | $0 |
| 24-Hour NurseLine | $0 |
| Preventive Care+ | |
| Pap Smears, Pelvic Exams and Mammograms | $0 |
| Prostate and Colorectal Cancer Screenings | $0 |
| Vaccinations (flu, pneumonia, hepatitis B, COVID-19)++ | $0 |
| Labs and Tests+ | |
| Lab Services | $0 |
| Diagnostic Procedures/Tests | $45 |
| X-rays | $0 |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $120 |
| Outpatient Surgery | |
| Surgery (outpatient hospital or ambulatory surgical center) | $125 |
| Inpatient Hospital Care per Admission | |
| Inpatient Deductible | $0 |
| Inpatient Stay per Day | $125 for days 1-10 $0 for days 11 and beyond |
| Home Health & Skilled Nursing Facility Care | |
| Home Health | $0 |
| Skilled Nursing Facility Care per Day (semiprivate room and board) | $0 for days 1-20 $203 for days 21-100 |
| Emergency Care, Urgent Care & Emergency Transportation^ | |
| Emergency Care | $120 |
| Urgently Needed Care | $20 |
| Emergency Ambulance Services per One-way Trip (ground or air) | $290 |
| Worldwide (out of U.S.) Emergency Care, Urgent Care and Emergency Transportation (to nearest facility) | $0 |
| Outpatient Services and Supplies | |
| Occupational, Physical or Speech Therapy Visit | $10 |
| Durable Medical Equipment - DME (wheelchairs, oxygen, etc.) | 20% coinsurance |
| Diabetes Monitoring Supplies (test strips, monitor, etc., from a DME provider or retail pharmacy) | $0 |
| Mental Health and Substance Abuse Treatment | |
| Inpatient Mental Health Care per Day | $125 for days 1-10 $0 for days 11-90 |
| Outpatient Mental Health Group or Individual Visit | $20 |
| Outpatient Substance Abuse Group or Individual Visit | $25 |
| Virtual Mental Health or Virtual Substance Abuse Treatment Visit | $0 |
| Costs listed are based on use of network providers. Authorization is required for certain services. +Office visit copay may apply. ++You will pay a $0 copay for all Part D-covered vaccines, including Shingrix, from network providers. ^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-name drugs have partial coverage through the gap. 100-day supplies of maintenance medications on tiers 1, 2, 3 and 4 are available at retail pharmacies and by mail order.
You will pay a maximum of $35 for each 1-month supply of Part D-covered insulin drugs through all drug payment stages, except the Catastrophic drug payment stage, where you pay $0.
You will pay a $0 copay for all Part D-covered vaccines, including Shingrix.
| Initial Coverage Stage | 30-Day Supply | 100-Day Supply |
| Tier 1 (with coverage through the gap) | $0 | $0 |
| Tier 2 (with coverage through the gap) | $10 | $0 (preferred mail order) |
| Tier 3 | $45 | $135 |
| Tier 4 | $100 | $300 |
| Tier 5 | 33% coinsurance | 30-day supply only |
| Peoples Health Choices 65 (HMO-POS) Southland | Your Cost |
| Over-the-Counter Items | |
| $40 Allowance per Quarter | $0 |
| Meals After Inpatient Hospital Stay | |
| Up to 28 Meals over 14 Days | $0 |
| Hearing Services | |
| Hearing Aids | Starting at $99 |
| Routine Hearing Exam | $0 |
| Vision Services | |
| Routine Eye Exam | $0 |
| Glasses or Contact Lenses (one pair per year - $250 allowance) | $0 |
| Dental - $2,500 Coverage Maximum | |
| Dental - Preventive (X-rays, cleanings, exams, fluoride - coverage frequency varies) | $0 |
| Dental - Comprehensive/Restorative | $0 |
| Dental – Bridges or Dentures | 50% coinsurance |
| 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 |
| Fitness | |
| Health Clubs, Online Classes, Brain Health Exercises and More | $0 |
Notes:
Costs listed are based on use of network providers.
Authorization is required for certain services.
Doctor and Hospital Coverage
| Peoples Health Choices 65 (HMO-POS) Southland | Your Cost |
| Monthly Plan Premium | $0 |
| Part B Premium Give Back | $15 per month back to you |
| Doctor Visits & NurseLine | |
| Primary Care Physician Visit | $0 |
| Specialist Visit | $30 |
| Virtual Medical Visit | $0 |
| 24-Hour NurseLine | $0 |
| Preventive Care+ | |
| Pap Smears, Pelvic Exams and Mammograms | $0 |
| Prostate and Colorectal Cancer Screenings | $0 |
| Vaccinations (flu, pneumonia, hepatitis B, COVID-19)++ | $0 |
| Labs and Tests+ | |
| Lab Services | $0 |
| Diagnostic Procedures/Tests | $45 |
| X-rays | $0 |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $120 |
| Outpatient Surgery | |
| Surgery (outpatient hospital or ambulatory surgical center) | $125 |
| Inpatient Hospital Care per Admission | |
| Inpatient Deductible | $0 |
| Inpatient Stay per Day | $125 for days 1-10 $0 for days 11 and beyond |
| Home Health & Skilled Nursing Facility Care | |
| Home Health | $0 |
| Skilled Nursing Facility Care per Day (semiprivate room and board) | $0 for days 1-20 $203 for days 21-100 |
| Emergency Care, Urgent Care & Emergency Transportation^ | |
| Emergency Care | $120 |
| Urgently Needed Care | $20 |
| Emergency Ambulance Services per One-way Trip (ground or air) | $290 |
| Worldwide (out of U.S.) Emergency Care, Urgent Care and Emergency Transportation (to nearest facility) | $0 |
| Outpatient Services and Supplies | |
| Occupational, Physical or Speech Therapy Visit | $10 |
| Durable Medical Equipment - DME (wheelchairs, oxygen, etc.) | 20% coinsurance |
| Diabetes Monitoring Supplies (test strips, monitor, etc., from a DME provider or retail pharmacy) | $0 |
| Mental Health and Substance Abuse Treatment | |
| Inpatient Mental Health Care per Day | $125 for days 1-10 $0 for days 11-90 |
| Outpatient Mental Health Group or Individual Visit | $20 |
| Outpatient Substance Abuse Group or Individual Visit | $25 |
| Virtual Mental Health or Virtual Substance Abuse Treatment Visit | $0 |
| Costs listed are based on use of network providers. Authorization is required for certain services. +Office visit copay may apply. ++You will pay a $0 copay for all Part D-covered vaccines, including Shingrix, from network providers. ^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. 100-day supplies of maintenance medications on tiers 1, 2, 3 and 4 are available at retail pharmacies and by mail order.
You will pay a maximum of $35 for each 1-month supply of Part D-covered insulin drugs through all drug payment stages, except the Catastrophic drug payment stage, where you pay $0.
You will pay a $0 copay for all Part D covered vaccines, including Shingrix.
| Initial Coverage Stage | 30-Day Supply | 100-Day Supply |
| Tier 1 (with coverage through the gap) | $0 | $0 |
| Tier 2 (with coverage through the gap) | $10 | $0 (preferred mail order) |
| Tier 3 | $45 | $135 |
| Tier 4 | $100 | $300 |
| Tier 5 | 33% coinsurance | 30-day supply only |
Additional Benefits
| Peoples Health Choices 65 (HMO-POS) Southland | Your Cost |
| Over-the-Counter Items | |
| $40 Allowance per Quarter | $0 |
| Meals After Inpatient Hospital Stay | |
| Up to 28 Meals over 14 Days | $0 |
| Hearing Services | |
| Hearing Aids | Starting at $99 |
| Routine Hearing Exam | $0 |
| Vision Services | |
| Routine Eye Exam | $0 |
| Glasses or Contact Lenses (one pair per year - $250 allowance) | $0 |
| Dental - $2,500 Coverage Maximum | |
| Dental - Preventive (X-rays, cleanings, exams, fluoride - coverage frequency varies) | $0 |
| Dental - Comprehensive/Restorative | $0 |
| Dental – Bridges or Dentures | 50% coinsurance |
| 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 |
| Fitness | |
| Health Clubs, Online Classes, Brain Health Exercises and More | $0 |
Notes:
Costs listed are based on use of network providers.
Authorization is required for certain services.
Find Doctors, Medications & More
Important Documents
Plan Overview for Peoples Health Choices 65 Southland – An overview of plan benefits
Annual Notice of Changes for Peoples Health Choices 65 Southland – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices 65 Southland – 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 Southland – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services
How to Enroll
Enroll Online
Enrolling online only takes about 20 minutes. You’ll need your red, white and blue Medicare card to complete the online application.
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. You can also request an enrollment packet.
By Appointment
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 sales representative will schedule an appointment
with you.