Ochsner Health Plan Freedom (HMO POS)
- 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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