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Ochsner Health Plan 2025 Freedom (HMO POS) H9763-004-002 | Medicare advantage plan with part d drugs and out-of-network coverage

St. Tammany Parish

$0 PLAN PREMIUM

per month

Medicare Advantage plan available in this parish:
St. Tammany

Get more than Original Medicare with these great benefits.

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$400 VISION

Exams, glasses & contacts.

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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) H9763-004-002 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 $4,500 per year
Doctor Visits
Primary Care Physician Visit $0 copay 20%
Specialist Visit $30 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.) $125 copay 20%
Therapeutic Radiology and Outpatient X-Rays $80 copay 20%
Outpatient Surgery
Surgery at Outpatient Hospital or Ambulatory Surgery Center $175 20%
Inpatient Hospital Stay
Inpatient Deductible $0 20%
Hospital Stay (days 1-10) $190 per day 20%
Hospital Stay (days 11 and beyond) $0 20%
Emergency and Urgent Care
Urgent Care $35 copay $35 copay
Emergency Care $125 copay $125 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 $190 for days 1-10 $0 for days 11-90 per admission. You pay these amounts until you reach the out-of-pocket maximum. 20%
Outpatient Mental Health Group or Individual Visit $25 copay 20%

Additional Benefits Not Covered by Original Medicare In Network Out of Network
Over-the-Counter Health & Wellness Items $90 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 5333% 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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