Ochsner Health Plan 2025 Premier (HMO) H9763-005 | MEDICARE ADVANTAGE PLAN WITH PART D DRUGS
Acadiana Region
Medicare Advantage plan available in these parishes: Acadia, Jefferson Davis, Lafayette, St. Landry, St. Martin, Vermilion
Get more than Original Medicare with these great benefits.
Plan Documents
Plan Benefits
| Ochsner Health Plan Premier (HMO) H9763-005 | Your Cost |
| Monthly Plan Premium | $0 |
| Part B Premium Give Back | $30 per month |
| Medicare Part D Prescription Drug Coverage | This plan includes Part D coverage |
| Maximum Out of Pocket | $3,700 per year |
| Doctor Visits | |
| Primary Care Physician Visit | $0 |
| Specialist Visit | $25 copay |
| Chiropractic Care | $20 copay |
| Preventive Care | |
| Pap Test, Pelvic Exams, Mammograms | $0 |
| Prostate and Colorectal Cancer Screenings | $0 |
| Vaccinations* | $0 |
| Labs & Tests | |
| Lab Services (at contracted lab provider) | $0 |
| Diagnostic Tests | $10 copay |
| Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) | $125 copay |
| Therapeutic Radiology and Outpatient X-Rays | $80 copay |
| Outpatient Surgery | |
| Surgery at Outpatient Hospital or Ambulatory Surgery Center | $150 copay |
| Inpatient Hospital Stay | |
| Inpatient Deductible | $0 |
| Hospital Stay (days 1-10) | $115 per day |
| Hospital Stay (days 11 and beyond) | $0 |
| Emergency and Urgent Care | |
| Urgent Care | $35 copay |
| Emergency Care | $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 |
| Outpatient Services & Supplies | |
| Diabetes Monitoring Supplies | $0 In-Network Pharmacy, 20% coinsurance from DME supplier |
| Occupational, Physical or Speech Therapy Visit | $20 copay per visit |
| Mental Health Treatment | |
| Inpatient Mental Health Care per Day | $115 for days 1-10 $0 for days 11-90 |
| Outpatient Mental Health Group or Individual Visit | $25 copay |
| Additional Benefits Not Covered by Original Medicare | Your Cost |
| 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). 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 | Routine hearing exams $20 copay 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 visits. Up to $3,000 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 (Silver & Fit) 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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