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Ochsner Health Plan Freedom (HMO POS)

The Freedom Plan allows you to get care from doctors, hospitals, pharmacies and other providers inside their network (called “in-network”), or, from outside their network. The difference is that if you use in-network providers, you’ll typically pay less in out-of-pocket costs. If you use out-of-network providers, you’ll still get some coverage from the plan, but your out-of-pocket costs will be higher.

To join Ochsner Health Plan Freedom, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and live in our service area. Our service area includes the following Louisiana Parishes: Ascension, East Baton Rouge, East Feliciana, Iberville, Jefferson, Lafourche, Livingston, Orleans, St. Charles, St. John the Baptist, St. Tammany, West Baton Rouge.

Premium and Benefit Detail

This is a summary of drug and health services covered by Ochsner Health Plan Freedom (HMO POS), Jan. 1, 2022 - Dec. 31, 2022. You can also download a complete 2022 Summary of Benefits brochure (PDF).

Premium Benefits

Ochsner Health Plan Freedom  (HMO POS) 

What You Should Know
Monthly Plan Premium  You pay $0  You must continue to pay your Medicare Part B premium. 
Part B Premium Reduction  N/A  There is no Part B reduction. 
Annual Medical Deductible  $0  There is no medical deductible 

Maximum Out-of-Pocket Responsibility (does not include prescription drugs or out-of-network services

$3,700 annually 

The most you pay for copays, coinsurance, and other costs for in-network medical services in a year.

Inpatient Hospital 

7 days, $0 copayment for additional
Medicare-covered days.

reach the out-of-pocket maximum.

Our plan covers an unlimited number of days for inpatient hospital stays. 

Your provider may need to obtain prior authorization. 

Out-of-network: 20% per stay

Outpatient Hospital 

  • Ambulatory Surgery Center 

In-network: $160 copay per visit 

$0 copay for diagnostic colonoscopy at an in-network facility 

Your provider may need to obtain prior authorization. 
Out of network: 20% coinsurance per visit 
  • Outpatient Hospital Including Surgery 

In-network: $130 copay per visit 

Your provider may need to obtain prior authorization. 
Out-of-network: 20% coinsurance per visit 
  • Outpatient Observation Services 

$0 copay 

Your provider may need to obtain prior authorization. 
Out-of-network: 20% coinsurance per visit 
Doctor Visits
  • Primary Care 

In-network: $0 copay 

 
Out-of-network: 20% coinsurance per visit 
  • Specialist Care 

In-network: $20 copay per visit 

 
Out-of-network: 20% coinsurance per visit 

Preventive Care (e.g. flu vaccine, COVID-19 vaccine, diabetic screenings, etc.) 

In-network: $0 copay 

Any additional preventive services approved by Medicare during the contract year will be covered.  
Out-of-network: 20% coinsurance 

Emergency Care (local and world-wide)

$90 copay per visit (for both in-network and out-of-network)  If you are admitted to the hospital within (1) day, the emergency room copay is waived. 
Urgently Needed Services (local and world-wide) $20 copay per visit (for both in-network and out-of-network)  If you are admitted to the hospital within (1) day, the urgent care copay is waived. 
Diagnostic Services/Labs/Imaging 
  • Diagnostic Radiology Services (e.g. MRI, etc) 

In-network: $0-$85 copay 

$0 copay for diagnostic mammogram 

Your provider may need to obtain prior authorization. 
Out-of-network: $20 coinsurance 
  • Lab Services 

In-network: $0 copay 

Your provider may need to obtain prior authorization. 
Out-of-network: 20% coinsurance 
  • Diagnostic Tests and Procedures 
In-network: $35 copay  Your provider may need to obtain prior authorization. 
Out-of-network: 20% coinsurance 
  • Therapeutic Radiology 
In-network: $35 copay  Your provider may need to obtain prior authorization. 
Out-of-network: 20% coinsurance 
  • Outpatient X-Rays 
In-network: $35 copay  Your provider may need to obtain prior authorization. 
Out-of-network: 20% coinsurance 
Hearing Services
  • Exam to diagnose and treat hearing and balance issues 
In-network: $20 copay   
Out-of-network: 20% coinsurance 
  • Routine Hearing Exam 
In-network: $20 copay  1 routine exam every year. 
Out-of-network: 20% coinsurance 
  • Hearing Aids 
In-network: $0 copay  Plan pays up to $500 for each ear per year. 
$1000 allowance every year 
Dental Services (In-network only)
  • Medicare covered $20 copay
    Medicare-covered Benefits limited
    to services provided under the
    Medicare program
$0 copay for oral exams, cleaning and x-rays. Medicare-covered Benefits limited to services provided under the Medicare program.  
  • Preventive Dental 
$50 deductible applies before coverage begins.
$11- $295 copay for restorative services
Preventive Dental (oral exams, cleaning, and dental x-ray) each service limited to (2) treatments per year
  • Comprehensive Dental 

$15 for extractions

$20-$217.75 copay for prosthetics, other oral/maxillofacial surgery, & other services.

Comprehensive Dental - Restorative Services; Periodontics; Extractions; Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 

Comprehensive and Preventive dental services are limited to up to $2000 in total combined 
cost per year. 

No out-of-network coverage.
Vision Services
  • Exam to diagnose and treat conditions and diseases of the eye 
In-network: $20 copay  
Out-of-network: 20% coinsurance 
  • Eyewear post-cataract surgery 
In-network: $0 copay  
Out-of-network: 20% coinsurance 
  • Routine Eye Exam (In-network only)
In-network: $0 copay 1 routine exam per year 
  • Eyewear (In-network only)
In-network: $0 copay Eyewear - Up to $200 every year
Mental Health Services 
  • Inpatient visit 
$65 copayment each day for days 1 - 4 for Medicare-covered hospital care. $0 copay for days 5-90.  
Out-of-network: 20% coinsurance 
  • Outpatient Group Therapy Visit 
In-network: $20 copay   
Out-of-network: 20% coinsurance 
  • Outpatient Individual Therapy Visit 
In-network: $20 copay   
Out-of-network: 20% coinsurance 
  • Skilled Nursing Facility (SNF) 
In-network: $0 per day for 1 through 20, $178 per day for days 21 through 100 

Our plan covers up to 100 days in a SNF. 

Zero (0) hospital days required prior to SNF admission. 

Out-of-network: 20% per day 
Therapy/Rehabilitation Services 
  • Occupational Therapy Visit 
In-network: $20 copay   
Out-of-network: 20% coinsurance 
  • Physical Therapy and Speech Therapy Visit

In-network: $20 copay   
Out-of-network: 20% coinsurance 
Ambulance (local and world-wide)

In-network: $235 copay for ground ambulance

20% coinsurance for air ambulance

Prior authorization may be required for Medicare-covered non-emergent ambulance.
Out-of-network: 20% coinsurance for ground ambulance
Medicare Part B Drugs  You pay 20% of the cost for Medicare-covered services  Your provider may need to obtain prior authorization. 
Home Health Services 

In-network: $0 copay

Your provider may need to obtain prior authorization. 
Out-of-network: 20% coinsurance 
Foot Care (Podiatry) 

In-network: $20 copay per visit 

Limited to six (6) routine podiatry services per year. 
Out-of-network: 20% coinsurance per visit 
Medical Equipment/Supplies 
Durable Medical Equipment (e.g. wheelchairs, oxygen, etc.)  In-network: 0-20% coinsurance per item

Your provider may need to obtain prior authorization. 

Out-of-network: 20% coinsurance per item
Prosthetics (e.g. braces, artificial limbs, etc.)  In-network: 0-20% coinsurance per item
Out-of-network: 20% coinsurance per item

Diabetes Supplies 

In-network: 0-20% coinsurance per item

Out-of-network: 20% coinsurance per item
Over-the-Counter (OTC) Items  You pay $0 for up to $75 per quarter of covered items. 

Plan provides $75 per quarter allowance for over-the-counter items and unused benefit are not carried forward for the next period and plan year

Members must select OTC items through the Ochsner Health Plan OTC catalog(PDF

Chiropractic Care 

In-network: $20 copay per visit 

Covered services include:
Manual manipulation of the spine to correct subluxation
Out-of-network: 20% coinsurance per visit 
Diabetes Management 
  • Diabetes Monitoring Supplies 
In-network: $0 copay per item   

Out-of-network: 20% coinsurance per item

  • Diabetes Self-management Training 
In-network: $0 copay per item   

Out-of-network: 20% coinsurance per item

  • Therapeutic Shoes or inserts 

In-network: $0 copay per item 

 

Out-of-network: 20% coinsurance per item

Fitness Program  In-network: $0 copay Must use network fitness facility. Program includes fitness tracker.
Meal Benefit  In-network: $0 copay 

Immediately following surgery or inpatient hospital stay. Nutritional need must meet CMS criteria for this benefit.

Allowance: 2 meals per day for 7 days per Medicare-covered inpatient discharge. No maximum number of meals per year.

Hospice  You pay nothing for hospice care from any Medicare-approved hospice You may have to pay part of the costs for drugs and respite care.  Hospice is covered by Original Medicare, outside of our plan. 
Opioid Treatment Services  In-network: $0 copay Must be provided by a CMS certified Opioid Treatment Services Program. 
Out-of-network: 20% coinsurance 
Outpatient substance abuse treatment – group or individual In-network; $20 copay Your provider may need to obtain prior authorization.
Out-of-network: 20% coinsurance 
Renal dialysis  In-network: 20% coinsurance Your provider may need to obtain prior authorization.
Out-of-network: 20% coinsurance 

 

Prescription Drugs

Stage 1: Annual Prescription Deductible

Since you have no deductible for Part D drugs, this payment stage doesn't apply

Stage 2:  Initial Coverage (After you pay your deductible, if applicable) Retail Mail Order
30-day supply 90-day supply 90-day supply
Tier 1: Preferred Generic Drugs $0 copay  $0 copay  $0 copay 

Tier 2: Generic Drugs1

$10 copay  $0 copay  $0 copay 

Tier 3: Preferred Brand Drugs 

$45 copay  $135 copay  $135 copay 
Select Insulin Drugs2 $35 copay  $105 copay  $105 copay 

Tier 4: Non-Preferred Brand Drugs 

$100 copay  $300 copay  $300 copay 

Tier 5: Specialty Tier Drugs 

33% coinsurance  N/A3 N/A3

Stage 3: Coverage Gap Stage 

Tier 1 and Tier 2 Drugs are covered in the gap. For covered drugs on other tiers, after your total drug costs reach $4,430, you pay 25% coinsurance for generic drugs and 25% coinsurance for brand name drugs during the coverage gap. 
Stage 4:  Catastrophic Coverage   After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050, you pay the greater of: $3.95 for those generic or preferred multisource drugs with a retail price under $79 and 5% for those with a retail price greater than $79. For brand-name drugs, you would pay $9.85 for those drugs with a retail price under $197 and 5% for those with a retail price over $197.

Other Limitations May Apply

1Tier includes enhanced drug coverage 

2 For 2022, this plan participated in the Insulin Senior Savings Program which offers lower, stable, and predictable out of pocket costs for covered insulin through the different Part D benefit coverage stages. You will pay a maximum of $35 for a 1-month supply of covered Senior Savings Program insulin during the deductible, initial coverage, and coverage gap or “donut hole” stages of your benefit. You will pay 5% of the cost of these covered insulin in the catastrophic stage. Your cost maybe less if you receive Extra Help from Medicare. 

3 Limited to a 30-day supply.   

Need More Details?

The information on these pages is just a summary of what the plan covers and what you’ll pay. It doesn’t list every possible service, or every limitation or rule. If you’d like a complete list of all services, please call Member Services toll-free at 833-674-2112. Just ask for “Evidence of Coverage.”

We are open:

  • Oct. 1 to Mar. 31: 8 a.m. to 8 p.m., seven days a week
  • Apr. 1 to Sept. 30: 8 a.m. to 8 p.m., Monday through Friday

TTY users: Please call 711 or visit www.ochsnerhealthplan.com.

Ready to Enroll?

Starting Oct. 15, 2021 you can enroll online or call 855-431-3423 to speak with an enrollment specialist from Ochsner Health Plan.