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.
| 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 |
In-network: $65 each day for 1 through 7 days; $0 for 8 through 90 days You pay these amounts until you reach the in-network 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 | ||
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Outpatient Hospital |
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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 | ||
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In-network: $130 copay per visit |
Your provider may need to obtain prior authorization. |
| Out-of-network: 20% coinsurance per visit | ||
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$0 copay |
Your provider may need to obtain prior authorization. |
| Out-of-network: 20% coinsurance per visit | ||
| Doctor Visits | ||
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In-network: $0 copay |
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| Out-of-network: 20% coinsurance per visit | ||
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In-network: $20 copay per visit |
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| Out-of-network: 20% coinsurance per visit | ||
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Preventive Care (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 | $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 | $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 | ||
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In-network: $0-$85 copay $0 copay for diagnostic mammogram |
Your provider may need to obtain prior authorization. |
| Out-of-network: $20 coinsurance | ||
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In-network: $0 copay |
Your provider may need to obtain prior authorization. |
| Out-of-network: 20% coinsurance | ||
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In-network: $35 copay | Your provider may need to obtain prior authorization. |
| Out-of-network: 20% coinsurance | ||
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In-network: $35 copay | Your provider may need to obtain prior authorization. |
| Out-of-network: 20% coinsurance | ||
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In-network: $35 copay | Your provider may need to obtain prior authorization. |
| Out-of-network: 20% coinsurance | ||
| Hearing Services | ||
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In-network: $20 copay | |
| Out-of-network: 20% coinsurance | ||
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In-network: $20 copay | 1 routineexam every year. |
| Out-of-network: 20% coinsurance | ||
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In-network: $0 copay | Plan pays up to $500 for each ear per year. |
| $1000 allowance every year | ||
| Dental Services | ||
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In-Network: $20 copay | Medicare-covered Benefits limited to services provided under the Medicare program. |
| Out of Network: 20% coinsurance | ||
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In-network: $0 copay for oral exams, cleaning and x-rays. | Preventive Dental (oral exams, cleaning, and dental x-ray) each service limited to 2 treatments per year |
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In-network: $50 deductible applies before coverage begins. |
Comprehensive Dental - Restorative Services; Endodontics; 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. |
| In-network: $0 copay for diagnostic services | ||
| In-network: $11- $295 copay for restorative services | ||
| In-network: $15 for extractions | ||
| In-network: $20-$217.75 copay for prosthetics, other oral/maxillofacial surgery, & other services | ||
| Vision Services | ||
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In-network: $20 copay | |
| Out-of-network: 20% coinsurance | ||
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In-network: $0 copay | |
| Out-of-network: 20% coinsurance | ||
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In-network: $0 copay | 1 routine exam per year |
| Out-of-network: 20% coinsurance | ||
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In-network: $0 copay | Eyewear - Up to $200 every year |
| Mental Health Services | ||
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$65 copayment each day for days 1 to 10 for Medicare-covered hospital care. $0 copayment for additional Medicare-covered days. | |
| Out-of-network: 20% coinsurance | ||
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In-network: $20 copay | |
| Out-of-network: 20% coinsurance | ||
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In-network: $20 copay | |
| Out-of-network: 20% coinsurance | ||
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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. 0 hospital days required prior to SNF admission. |
| Out-of-network: 20% per day | ||
| Rehabilitative Services | ||
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In-network: $20 copay | |
| Out-of-network: 20% coinsurance | ||
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In-network: $20 copay | |
| Out-of-network: 20% coinsurance | ||
| Ambulance | In-network: $235 copay for ground ambulance | Prior authorization may be required for Medicare-covered non-emergent ambulance. |
| Out-of-network: 20% coinsurance for ground ambulance | ||
| 20% coinsurance for air ambulance | ||
| Transportation | Not Covered | |
| Medicare Part B Drugs | You pay 20% of the cost for Medicare-covered services | Prior authorization is required for billed charges over $250. |
| Home Health Services |
In-network: $0 copay |
Prior Authorization required. |
| Out-of-network: 20% coinsurance | ||
| Foot Care (Podiatry) |
In-network: $20 copay per visit |
Limited to 6 routine podiatry services per year. |
| Out-of-network: 20% coinsurance per visit | ||
| Medical Equipment/Supplies | ||
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In-network: 0-20% coinsurance per item Out-of-network: 20% coinsurance per item |
Prior authorization is required for billed charges over $250. |
| Over-the-Counter (OTC) Items | You pay $0 for up to $75 per quarter of covered items. |
Plan provides $75 per quarter allowance for OTC item, and you must use those funds in that quarter; you can’t carry them forward. Items must be on the list provided by Plan and purchased from Plan’s contracted vendor. |
| Chiropractic Care |
In-network: $20 copay per visit |
Includes manual manipulation of the spine to correct subluxation. |
| Out-of-network: 20% coinsurance per visit | ||
| Diabetes Management | ||
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In-network: $0 copay per item | |
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Out-of-network: 20% coinsurance per item |
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In-network: $0 copay per item | |
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Out-of-network: 20% coinsurance per item |
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In-network: $0 copay per item |
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Out-of-network: 20% coinsurance per item |
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| Health Education | In-network: $0 copay | Get help over the phone from a clinical team who can help you manage chronic conditions. |
| Fitness Program | In-network: $0 copay | Must use an in-network fitness facility. |
| Meal Benefit | In-network: $0 copay |
For use immediately following surgery or inpatient hospital stay. Nutritional need must meet CMS criteria. 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 | |
| Out-of-network: 20% coinsurance | ||
| Renal dialysis | In-network; $20 copay | |
| 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 |
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| 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 |
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Tier 2: Generic Drugs1 |
$10 copay | $0 copay | $0 copay |
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Tier 3: Preferred Brand Drugs |
$45 copay | $135 copay | $135 copay |
| Select Insulin Drugs2 | $35 copay | $105 copay | $105 copay |
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Tier 4: Non-Preferred Brand Drugs |
$100 copay | $300 copay | $300 copay |
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Tier 5: Specialty Tier Drugs |
33% coinsurance | N/A3 | N/A3 |
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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.