Ochsner Health Plan 2025 Dual (HMO D-SNP) H9763-007 | MEDICARE ADVANTAGE plan for people with medicare & medicaid or assistance from the state
For people with Medicare and Medicaid or Assistance from the State
Available in these parishes:
Jefferson, Orleans, Plaquemines, St. Bernard, St. Charles
Benefits designed for your health.
Plan Documents
Plan Benefits
| Ochsner Health Plan Dual (HMO D-SNP) | Your Cost |
| Monthly Plan Premium | $0 |
| Medicare Part D Prescription Drug Coverage | $0 |
| Doctor Visits | |
| Primary Care Physician Visit | $0 or 20% copay |
| Specialist Visit | $0 or 20% copay |
| Chiropractic Care | $0 or 20% copay |
| Preventive Care | |
| Pap Test, Pelvic Exams, Mammograms | $0 or 20% copay |
| Prostate and Colorectal Cancer Screenings | $0 or 20% copay |
| Vaccinations* | $0 or 20% copay |
| Labs & Tests | |
| Lab Services (at contracted lab provider) | $0 or 20% copay |
| Diagnostic Tests | $0 or 20% copay |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $0 or 20% copay |
| Therapeutic Radiology and Outpatient X-Rays | $0 or 20% copay |
| Outpatient Surgery | |
| Surgery at Outpatient Hospital or Ambulatory Surgery Center | $0 or 20% copay |
| Inpatient Hospital Stay | |
| Inpatient Deductible | $0 |
| Hospital Stay (days 1-60) | $0 after you pay your Medicare Part A deductible |
| Emergency and Urgent Care | |
| Urgent Care | $35 |
| Emergency Care | $0 or 20% copay |
| Emergency & Urgent Care | If you are admitted to the hospital within one (1) day, the copay is waived. Covered Worldwide |
| Emergency Ambulance Service (per one day trip, ground or air) | $235 ground 20% air |
| Outpatient Services & Supplies | |
| Diabetes Monitoring Supplies | $0 or 20% copay |
| Occupational, Physical or Speech Therapy Visit | $0 or 20% copay |
| Mental Health Treatment | |
| Inpatient Mental Health Care per Day | $0 or 20% copay |
| Outpatient Mental Health Group or Individual Visit | $0 or 20% copay |
| Additional Benefits Not Covered by Original Medicare | Your Cost |
| Over-the-Counter Health & Wellness Items, Non-emergency Transportation, Groceries, and Utilities | $252 Flex Card credit allowance on a Visa card for over-the-counter items, groceries, non-emergency transportation, and utilities. |
| Routine Vision Exam (1 per calendar year) | $0 copay for routine vision exam (through contracted provider). No out of network coverage. |
| Glasses or Contact Lenses | Up to $400 allowance per calendar year (through contracted provider). No out of network coverage. |
| Hearing aids, Routine hearing exams, Hearing aid fitting/evaluations | Up to $2,000 combined maximum allowance per calendar year (through contracted provider). All plans from Ochsner Health Plan include access to routine hearing care, including prescription hearing aids, routine hearing exams, and fittings/evaluations for hearing aids. As a member, you'll receive a Visa debit card preÂloaded with funds for you to use to pay for your hearing aids and exams. All plans from Ochsner Health Plan include access to routine hearing care, including prescription hearing aids, routine hearing exams, and fittings/evaluations for hearing aids. As a member, you'll receive a Visa debit card preÂloaded with funds for you to use to pay for your hearing aids and exams. |
| Dental Coverage - Preventive and Comprehensive | $0 copay for Medicare-covered visit. Up to $3,500 combined maximum allowance per calendar year for preventive and comprehensive dental services. You pay a 25% coinsurance for the following services (through a contracted provider): • Restorative services • Endodontics • Periodontic • Prosthodontics • Oral and Maxillofacial Surgery • Adjunctive General Services No out of network coverage. |
| Health Club Membership (SilverSneakers) with Ochsner Fitness Centers included: Downtown, Harahan, Heritage Plaza | $0 copay (through contracted provider SilverSneakers) |
| Post Discharge Home Meal Delivery (inpatient hospital stay or skilled nursing facility stay) | $0 copay (through contracted provider) |
| Additional Benefits - Part D Drug Coverage | Your Cost | |||
| Drug Tier | Standard retail cost sharing (in-network) (up to a 30-day supply) | Mail-order cost sharing (up to a 30-day supply) | Long-term care (LTC) cost sharing (up to a 31-day supply) | Out-of-network cost sharing (Coverage is limited to certain situations; see Chapter 5 for details.) (up to a 30-day supply) |
| Cost-Sharing Tier 1 (Generic and brand name drugs) | 0% or 25% coinsurance depending on your level of Medicaid eligibility | 0% or 25% coinsurance depending on your level of Medicaid eligibility | 0% or 25% coinsurance depending on your level of Medicaid eligibility | 0% or 25% coinsurance depending on your level of Medicaid eligibility |
| Insulin | $35 - You won’t pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier, even if you haven’t paid your deductible. | |||
| 90-day Supply | ||||
| Drug Tier | Standard retail cost sharing (in-network) (up to a 90-day supply) | Mail-order cost sharing (up to a 90-day supply) | ||
| Cost-Sharing Tier 1 (Generic and brand name drugs) | 0% or 25% coinsurance depending on your level of Medicaid eligibility | 0% or 25% coinsurance depending on your level of Medicaid eligibility | ||
| Insulin | You won’t pay more than $70 for up to a two-month supply or $105 for up to a three-month supply of each covered insulin product regardless of the cost-sharing tier, even if you haven’t paid your deductible. |
Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. Call our Pharmacy Help Desk for more information: 1-800-910-1837, TTY users should call 711. Hours are 24 hours a day/365 days a year.
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