Quick Guide Peoples Health Choices 65 #14 (HMO) Jefferson, Orleans and Plaquemines parishes

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1 Quick Guide 2016 $0 mium* Plan Pre Peoples Health Choices 65 #14 (HMO) Jefferson, Orleans and Plaquemines parishes *You must continue to pay your Medicare Part B premium. H1961_PH16C65S1QG Accepted

2 Thank you for your interest in Peoples Health Choices 65 #14. This Quick Guide highlights many of the benefits of this Medicare Advantage plan. If you choose to join this plan, Peoples Health will provide all of your Medicare Part A (hospital), Part B (medical) and Part D (prescription drug) coverage. This plan also provides additional benefits not available through Original Medicare. But the benefits are just the beginning. Every Peoples Health plan member has the support of a community-based Medicare Health Team to help them make the most of their plan. It s a personalized approach to healthcare, and it allows us to focus on the specific needs of each plan member. We encourage you to speak with a plan representative to learn more about Peoples Health, about our approach to healthcare and about the benefits of this plan. This plan is available to people with Medicare in Jefferson, Orleans and Plaquemines parishes. Do you make less than $1,345 per month? If your monthly income is less than $1,345,* you may qualify for assistance through Medicaid. With both Medicare and Medicaid, you may want to take a look at Peoples Health Secure Health (HMO SNP) a plan with low or no copays for many services. This plan is available to anyone who has both medical assistance from the state and Medicare. To learn more, call Peoples Health. You may be able to get more benefits, better coordinated care and bigger savings than you re getting now. *Amount listed is for 2015 and may change for 2016.

3 Peoples Health Choices 65 #14 Jefferson, Orleans and Plaquemines Parishes Monthly Plan Premium Physician Services Primary Care Physician Visit You pay $4. Specialist Visit You pay $35. Labs and Tests* + Lab Services, Diagnostic Tests, X-rays Advanced Imaging (MRI, MRA, CT, CTA and PET scans) and Nuclear Medicine Inpatient Hospital Care You pay $150. Semiprivate Room and Board $0 deductible. You pay $85 each day for days 1-10 of your stay. Out-of-pocket costs limited to $850 per stay. Outpatient Surgery Outpatient Surgery You pay $100. Chemotherapy Drugs Medicare Part B Chemotherapy Drugs You pay 15% coinsurance. Emergency and Urgent Care Emergency Care You pay $65. (Waived if admitted to inpatient hospital care within 24 hours for the same condition.) Urgently Needed Care You pay $35. Worldwide Coverage Up to $5,000 of coverage for emergency and urgently needed care (combined) outside the U.S. and its territories. Emergency Transportation Emergency Ambulance Services You pay $200 for each one-way trip. This information is not a complete description of benefits. Contact the plan for more information. You must live in the plan service area and have both Part A and Part B to enroll. Limitations, copayments and restrictions may apply. Benefits, premiums and copayments or coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

4 Exams, Screenings and Immunizations + Peoples Health Choices 65 #14 Jefferson, Orleans and Plaquemines Parishes Pap Smears, Pelvic Exams, Mammograms Prostate and Colorectal Cancer Screenings Bone Mass Measurement Vaccinations (flu, pneumonia, hepatitis B) Outpatient Services and Supplies Occupational, Physical and Speech Therapy Durable Medical Equipment (DME) (wheelchairs, oxygen, etc.) Diabetes Monitoring Supplies (test strips, lancets, monitor, etc., from a preferred DME provider) Mental Health and Substance Abuse Inpatient Mental Health Care Outpatient Mental Health Care and Substance Abuse Treatment You pay $10 per visit. (Medicare limits apply.) You pay 20% coinsurance. $0 deductible. You pay $85 each day for days 1-10 of your stay and $0 for days You pay $35 per visit. Skilled Nursing Facility Care Semiprivate Room and Board You pay $0 for days 1-20 and $150 each day for days Home Health Care Home Health Care Hearing Hearing Services You pay $35 for each Medicare-covered diagnostic exam. *See the plan Provider Directory for network lab and diagnostic providers. Lab services, diagnostic tests and X-rays at a doctor s offce or outpatient hospital may have higher out-of-pocket costs. + Offce visit copay may apply.

5 Nonemergency Transportation Peoples Health Choices 65 #14 Jefferson, Orleans and Plaquemines Parishes Additional Benefits Not Provided by Original Medicare Routine Transportation (such as trips to and from your doctor s offce) You pay $5 per trip for up to 12 one-way trips per year (plus up to 12 additional trips for dialysis) within 30 miles of your home. Vision Services Routine Vision Services You pay $35 for one routine eye exam per year and $0 for one pair of eyeglasses or contacts per year. Dental up to $1,500 in coverage Oral Exams You pay $0 (one every six months). X-rays You pay $0 (one set every year). Cleanings You pay $0 (one every six months). Comprehensive Services Copays vary for comprehensive services not covered by Medicare. $50 deductible applies. Fitness Health Club Membership Part D Prescription Drug Coverage Mail-Order Available? Coverage Through the Gap! All tier 1 and 2 generics are covered through the Medicare Part D coverage gap. Choose from over 185 fitness centers. Network Retail Pharmacies For up to a 30-day supply, you pay: Preferred Pharmacy Standard Pharmacy Tier 1: $0 $4 Tier 2: $10 $15 Tier 3: $37 $47 Tier 4: $80 $90 Tier 5: 33% coinsurance 33% coinsurance Yes, 90-day supplies of maintenance medications are available. Mail-order prescriptions for maintenance medications are available through our network mail-order pharmacy. You can sign up for optional automatic delivery. Mail-order prescriptions typically arrive within 10 days after the pharmacy receives your order. If you do not receive your drugs within the estimated time frame, please call Member Services at one of the numbers listed on your plan ID card.

6 You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call: Medicare MEDICARE ( ) 24 hours a day, 7 days a week TTY users should call Social Security Administration Monday through Friday, 7 a.m. to 7 p.m. TTY users should call Louisiana Medicaid Monday through Friday, 6:30 a.m. to 4:30 p.m. TTY users should call Or call Peoples Health, and we will help you find out if you qualify for extra help. On the cover: Members of Peoples Health plans. Inside: Margaret and Joseph S., Peoples Health plan members. For more information, call toll-free: (TTY: 711) 8 a.m. to 8 p.m. Seven days a week from September 1 through February 14 Monday through Friday from February 15 through August 31 Asistencia disponible en español. Peoples Health Three Lakeway Center 3838 N. Causeway Blvd., Suite 2200 Metairie, LA Peoples Health is a Medicare Advantage organization with a Medicare contract to offer HMO plans. Enrollment depends on annual Medicare contract renewal.

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