Ochsner Health Plan 2025 Freedom (HMO POS) H9763-004-001 | Medicare advantage plan with part d drugs and out-of-network coverage
Baton Rouge & New Orleans
Medicare Advantage plan available in these parishes: Ascension, East Baton Rouge, East Feliciana, Iberville, Jefferson, Lafourche, Livingston, Plaquemines, Orleans, St. Bernard, St. Charles, St. John the Baptist, West Baton Rouge
Get more than Original Medicare with these great benefits.
$3,000 DENTAL
per year with no deductible.
$400 VISION
Exams, glasses & contacts.
PPO FLEXIBILITY
Stay in network and save, or see out-of-network providers for 20% coinsurance.
Plan Documents
Plan Benefits
| Ochsner Health Plan Freedom (HMO POS) H9763-004-001 | In Network | Out of Network |
| Monthly Plan Premium | $0 | |
| Medicare Part D Prescription Drug Coverage | This plan includes Part D coverage | |
| Maximum Out of Pocket | $4,100 per year | |
| Doctor Visits | ||
| Primary Care Physician Visit | $0 copay | 20% |
| Specialist Visit | $25 copay | 20% |
| Chiropractic Care | $20 copay | 20% |
| Preventive Care | ||
| Pap Test, Pelvic Exams, Mammograms | $0 | 20% |
| Prostate and Colorectal Cancer Screenings | $0 | 20% |
| Vaccinations* | $0 | $0 |
| Labs & Tests | ||
| Lab Services (at contracted lab provider) | $0 | 20% |
| Diagnostic Tests | $10 copay | 20% |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $85 copay | 20% |
| Therapeutic Radiology and Outpatient X-Rays | $80 copay | 20% |
| Outpatient Surgery | ||
| Surgery at Outpatient Hospital or Ambulatory Surgery Center | $130 | 20% |
| Inpatient Hospital Stay | ||
| Inpatient Deductible | $0 | 20% |
| Hospital Stay (days 1-10) | $175 per day | 20% |
| Hospital Stay (days 11 and beyond) | $0 | 20% |
| Emergency and Urgent Care | ||
| Urgent Care | $35 copay | $35 copay |
| Emergency Care | $140 copay | $140 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 | 20% coinsurance for ground or air ambulance |
| Outpatient Services & Supplies | ||
| Diabetes Monitoring Supplies | $0 In-Network Pharmacy, 20% coinsurance from DME supplier | 20% coinsurance per item |
| Occupational, Physical or Speech Therapy Visit | $20 copay | 20% |
| Mental Health Treatment | ||
| Inpatient Mental Health Care per Day | $175 for days 1-10 $0 for days 11-90 | 20% |
| Outpatient Mental Health Group or Individual Visit | $20 copay | 20% |
| Additional Benefits Not Covered by Original Medicare | In Network | Out of Network |
| Over-the-Counter Health & Wellness Items | $110 credit per calendar quarter from OTC Catalog | |
| Routine Vision Exam (1 per calendar year) | $20 copay for routine vision exam (through contracted provider) | 20% coinsurance |
| Glasses or Contact Lenses | Up to $400 allowance per calendar year (through contracted provider) | 20% coinsurance |
| Hearing aids, Routine hearing exams, Hearing aid fitting/evaluations | Routine hearing exams $20 copay Up to $2,000 combined maximum allowance per calendar year (through contracted provider) | 20% coinsurance |
| Dental Coverage - Preventive and Comprehensive | $0 copay per Medicare-covered visit. Up to $3,000 combined maximum allowance per calendar year for preventive and comprehensive dental services. (through contracted provider) | |
| Health Club Membership (SilverSneakers) 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 | |
| Part D Deductible | $0 | |
| Drug Tier | 30-Day Supply Initial Coverage Stage | 90-Day Supply Initial Coverage Stage Retail & Mail Order |
| Tier 1 (preferred generics) | $0 | $0 |
| Tier 2 (Generics1) | $10 | $25 |
| Tier 3 (Preferred Brands) | $45 | $135 |
| Covered Insulin Drugs2 | $35 | $105 |
| Tier 4 (Non-Preferred Brands) | $100 | $300 |
| Tier 53 | 33% coinsurance | 30-day supply only |
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.
1Tier includes enhanced drug coverage.
2Important Message About What You Pay for Select Insulin - You won’t pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier.
3Limited up to a 30-day supply.
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