Ochsner Health Plan freedom (HMO POS) H9763-004-002
St. Tammany
Available in these parishes:
St. Tammany
Out-of-Network Coverage
Coordinated care and additional savings when using in-network providers
Get more than Original Medicare with these great benefits.
Plan Benefits
| Ochsner Health Plan Freedom (HMO POS) H9763-004-002 St. Tammany | 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 | $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) | $175 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 | $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 | $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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