Ochsner Health Plan FREEDOM (HMO POS) H9763-004-001

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Baton Rouge and New Orleans Region


per month

Available in these parishes:
Ascension, East Baton Rouge, East Feliciana, Iberville, Jefferson, Lafourche, Livingston. Orleans, St. Charles, St. John, West Baton Rouge

Out-of-Network Coverage

Coordinated care and additional savings when using in-network providers

Get more than Original Medicare with these great benefits.

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Flex Card for over-the-counter items.

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$3,000 DENTAL

per year with no deductible.

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$2,000 HEARING

coverage per year.

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Exams, glasses & contacts.

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$0 SilverSneakers Membership

Plan Benefits

Ochsner Health Plan Freedom (HMO POS) H9763-004-001
Baton Rouge / New Orleans Region
In Network Out of Network
Monthly Plan Premium $0
Part B Premium Give Back This plan does not include a Part B Give Back.
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 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 $35 copay 20%
Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) $85 copay 20%
Therapeutic Radiology and Outpatient X-Rays $35 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) $65 per day 20%
Hospital Stay (days 11 and beyond) $0 20%
Emergency and Urgent Care
Urgent Care $25 copay $25 copay
Emergency Care $90 copay $90 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 $65 for days 1-10 $0 for days 11-90 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 $85 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
Coverage through the Part D Coverage Gap Tier 1 and Tier 2
Drug Tier 30-Day Supply Initial Coverage Stage 90-Day Supply Initial Coverage Stage Retail & Mail Order
Tier 1 (with coverage through the gap) $0 $0
Tier 2 (with coverage through the gap) $10 $25
Tier 3 $45 $135
Covered Insulin Drugs** $35 $105
Tier 4 $100 $300
Tier 5 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.

**Important Message About What You Pay for Select Insulin -You won’t pay more than $35 for a one-month supply of each Select Insulin product covered by our plan, no matter what cost-sharing tier it’s on.

Tier 1 and Tier 2 Drugs are covered in the gap. For covered drugs on other tiers, after your total drug costs reach $5,030, you pay 25% coinsurance for generic drugs and 25% coinsurance for brand name drugs during the coverage gap.

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