Ochsner Health Plan Premier (HMO) H9763-005
Lafayette and St. Martin
Available in these parishes:
Lafayette, St. Martin
Get more than Original Medicare with these great benefits.
$30 PART B GIVE BACK
That's $360 per year back to you!
$3,000 DENTAL
per year with no deductible.
$400 VISION
Exams, glasses & contacts.
Plan Benefits
| Ochsner Health Plan Premier (HMO) H9763-005 Lafayette St. Martin Region | Your Cost |
| Monthly Plan Premium | $0 |
| Part B Premium Give Back | Up to $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) | $85 per day |
| Hospital Stay (days 11 and beyond) | $0 |
| Emergency and Urgent Care | |
| Urgent Care | $25 copay |
| Emergency Care | $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 |
| 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 | $20 copay |
| Additional Benefits Not Covered by Original Medicare | Your Cost |
| 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) |
| Glasses or Contact Lenses | Up to $400 allowance per calendar year (through contracted provider) |
| 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) |
| 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 (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 | |
| 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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