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Peoples Health Choices 65 (HMO-POS) Rural Southeast | 2023
H1961-014-004
A Medicare Advantage plan with Part D prescription drug coverage. Available in the following parishes:
Plaquemines, Pointe Coupee, St. Bernard, St. James, St. John the Baptist, West Feliciana
$0
Primary Care
Physician visit
$60/quarter
Over-the-Counter
Health Related Items
$30/month
Part B Premium
Give Back
$0
Primary Care
Physician visit
$60/quarter
Over-the-Counter
Health Related Items
$30/month
Part B Premium
GiveBack
You asked for more. We listened!
Now it’s easier than ever to picture yourself with Peoples Health. Every year, we look for ways to take care of our members better. The enhancements we’ve made for 2023 are designed to do just that. Look for:
More doctors
We've added more doctors to our Louisiana network.
More dentists & more dental coverage
We've added 95% more network dental locations^, and all plans now feature out-of-network dental coverage, a $0 deductible, $0 restorative services and an expanded list of covered services.*
More eye doctors
We've more than doubled our network of vision providers.
More savings
For many of our plans, there are lower copays and bigger allowances for select services, as well as lower maximum out-of-pocket costs.
More flexibility
Use our new retail card for over-the-counter health & wellness purchases. Also enjoy a retail option to get diabetes testing supplies at local network pharmacies.
^ Compared to 2022 Peoples Health network.
* Point-of-service (POS) option allows out-of-network dental services. Those out-of-network services may have a higher cost to members. Dental coverage maximums vary by plan.
Plan Highlights
$0 Primary
Care Visits
$60 Over-the-Counter
Allowance per Quarter
$0 Respite
Care Services
$0 Tier 1 & 2
Drug Coverage*
$0
Dental Exams,
Cleanings & X-rays
$0 Meals
After Inpatient
Hospital Stay
$0
Eyeglasses
or Contacts
One Pass™
Fitness†
*$0 Tier 2 drugs available by preferred mail-order as a 100-day supply.
†One Pass is a trademark of Optum, Inc. and/or its affiliates. © 2022 Optum, Inc.
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) Rural Southeast | Your Cost |
| Monthly Plan Premium | $0 |
| Part B Premium Give Back | $30 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 Tests and X-rays | $0 |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $55 |
| Outpatient Surgery | |
| Surgery (outpatient hospital or ambulatory surgical center) | $125 |
| Inpatient Hospital Care per Admission | |
| Inpatient Deductible | $0 |
| Inpatient Stay per Day, for Days 1-10 | $85 |
| Inpatient Stay for Days 11 and Beyond | $0 |
| Home Health & Skilled Nursing Facility Care | |
| Home Health | $0 |
| Skilled Nursing Facility Care per Day (semiprivate room and board) | $0 for days 1-20 $196 for days 21-100 |
| Emergency Care, Urgent Care & Emergency Transportation^ | |
| Emergency Care | $90 |
| Urgently Needed Care | $20 |
| Emergency Ambulance Services per One-way Trip (ground or air) | $250 |
| Worldwide (out of USA) 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 | $85 per day for days 1-10 $0 per day 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. *X-rays at network locations other than a radiology facility may have higher out-of-pocket costs. ^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 select insulin drugs through all coverage stages.
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) Rural Southeast | Your Cost |
| Over-the-Counter Items | |
| $60 Allowance per Quarter | $0 |
| Meals After Inpatient Hospital Stay | |
| Up to 28 Meals Over 14 Days | $0 |
| Vision Services | |
| Routine Eye Exam | $0 |
| Glasses or Contact Lenses (one pair per year - $200 Allowance) | $0 |
| Hearing Services | |
| Hearing Aids | Starting at $175 |
| Routine Hearing Exam | $0 |
| Dental - $2,000 Coverage Maximum | |
| Dental - Preventive (X-rays, cleanings, exams, fluoride - coverage frequency varies) | $0 |
| Dental - Comprehensive (fillings, crowns, bridges, dentures, etc.) | $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 |
| Fitness | |
| One Pass™ Fitness Membership (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) Rural Southeast | Your Cost |
| Monthly Plan Premium | $0 |
| Part B Premium Give Back | $30 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 Tests and X-rays | $0 |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $55 |
| Outpatient Surgery | |
| Surgery (outpatient hospital or ambulatory surgical center) | $125 |
| Inpatient Hospital Care per Admission | |
| Inpatient Deductible | $0 |
| Inpatient Stay per Day, for Days 1-10 | $85 |
| Inpatient Stay for Days 11 and Beyond | $0 |
| Home Health & Skilled Nursing Facility Care | |
| Home Health | $0 |
| Skilled Nursing Facility Care per Day (semiprivate room and board) | $0 for days 1-20 $196 for days 21-100 |
| Emergency Care, Urgent Care & Emergency Transportation^ | |
| Emergency Care | $90 |
| Urgently Needed Care | $20 |
| Emergency Ambulance Services per One-way Trip (ground or air) | $250 |
| Worldwide (out of USA) 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 | $85 per day for days 1-10 $0 per day 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. *X-rays at network locations other than a radiology facility may have higher out-of-pocket costs. ^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 select insulin drugs through all coverage stages.
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) Rural Southeast | Your Cost |
| Over-the-Counter Items | |
| $60 Allowance per Quarter | $0 |
| Meals After Inpatient Hospital Stay | |
| Up to 28 Meals Over 14 Days | $0 |
| Vision Services | |
| Routine Eye Exam | $0 |
| Glasses or Contact Lenses (one pair per year - $200 Allowance) | $0 |
| Hearing Services | |
| Hearing Aids | Starting at $175 |
| Routine Hearing Exam | $0 |
| Dental - $2,000 Coverage Maximum | |
| Dental - Preventive (X-rays, cleanings, exams, fluoride - coverage frequency varies) | $0 |
| Dental - Comprehensive (fillings, crowns, bridges, dentures, etc.) | $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 |
| Fitness | |
| One Pass™ Fitness Membership (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
Find Doctors, Medications & More
Important Documents
Plan Overview for Peoples Health Choices 65 Rural Southeast – An overview of plan benefits
Annual Notice of Changes for Peoples Health Choices 65 Rural Southeast – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices 65 Rural Southeast – 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 Rural Southeast – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services
Extra Help
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 (HMO-POS) Rural Southeast’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-POS) Rural Southeast* |
| 100% | $0 |
| 75% | $0 |
| 50% | $0 |
| 25% | $0 |
*This does not include any Medicare Part B premium you may have to pay.