Ochsner Health Plan Freedom (HMO POS)

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  • Out-of-network coverage:
    Coordinated care and additional savings when using in-network providers
  • $85 credit per calendar quarter for over-the-counter health & wellness items from OTC Catalog
  • 24-hour Nurse Hotline 
  • Medicare Part D prescription drug coverage
  OHP Freedom (HMO POS) In-network Out-of-network
Monthly Plan Premium $0 $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 and Nurse Hotline
Primary Care Physician Visit $0 copay 20%
Specialist Visit $20 copay 20%
24-Hour Nurse Line $0 copay $0 copay
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 20% 
Advanced Imaging (MRI, MRA, CT, CTA, PET scans, etc.) $85 20% 
Outpatient Surgery
 
Surgery at Outpatient Hospital or Ambulatory Surgery Center $130  20%
Inpatient Hospital Stay  
Inpatient Deductible $0 $0 
Hospital Stay (days 1-7) $65 per day 20%
Hospital Stay (days 8 and beyond) $0 20%

  Emergency and Urgent Care

 

Urgent Care $20 copay $20 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
 

  Additional Benefits Not Covered by Original Medicare

 

Over-the-Counter Health & Wellness Items $85 credit per calendar quarter from OTC Catalog N/A
Routine Vision Exam (1 per calendar year) $0 copay for routine vision exam (through contracted provider) N/A
Glasses or Contact Lenses Up to $200 allowance per calendar year (through contracted provider) N/A 
Hearing Aids Up to $1,000 per calendar year for both ears combined (through contracted provider) N/A 
Dental Coverage - Preventive and Comprehensive Up to $2,000 per calendar year, $50 comprehensive deductible applies before coverage begins (through contracted provider) N/A 
Health Club Membership
Ochsner Fitness Centers included: Downtown, Harahan, Heritage Plaza
$0 copay
(through contracted provider Silver&Fit)
N/A  
Post Discharge Home Meal Delivery (inpatient hospital stay or skilled nursing facility stay) $0 copay (through contracted provider) N/A  
Additional Benefits – Part D Drug Coverage
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 $0
Tier 3 $45 $135
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 are24 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.

 

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