Ochsner Health Plan Premier (HMO) H9763-003-001
Baton Rouge and New Orleans Region
Available in these parishes:
Ascension, East Baton Rouge, East Feliciana, Iberville, Jefferson, Lafourche, Livingston, Orleans, St. Charles, St. John, West Baton Rouge
Get more than Original Medicare with these great benefits.
Plan Benefits
Ochsner Health Plan Premier (HMO) H9763-003-001 Baton Rouge / New Orleans 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 | $2,900 per year |
Doctor Visits | |
Primary Care Physician Visit | $0 |
Specialist Visit | $20 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.) | $20 copay |
Therapeutic Radiology and Outpatient X-Rays | $20 copay |
Outpatient Surgery | |
Surgery at Outpatient Hospital or Ambulatory Surgery Center | $100 |
Inpatient Hospital Stay | |
Inpatient Deductible | $0 |
Hospital Stay (days 1-10) | $65 per day |
Hospital Stay (days 11 and beyond) | $0 |
Emergency and Urgent Care | |
Urgent Care | $20 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 | $10 copay |
Mental Health Treatment | |
Inpatient Mental Health Care per Day | $65 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 | $105 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. |
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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