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.
$3,500 DENTAL
per year with no deductible.
$400 VISION
Exams, glasses & contacts.
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 | $252 Flex Card credit per month from OTC Catalog |
| Routine Vision Exam (1 per calendar year) | $0 copay for routine vision exam (through contracted provider) |
| Glasses or Contact Lenses | Up to $400 allowance per calendar year (through contracted provider) |
| Hearing aids, Routine hearing exams, Hearing aid fitting/evaluations | Routine hearing exams $0 copay. Up to $2,000 combined maximum allowance per calendar year (through contracted provider) |
| Dental Coverage - Preventive and Comprehensive | $0 copay for Medicare-covered. Up to $3,500 combined maximum allowance per calendar year for preventive and comprehensive dental services. |
| 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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