Ochsner Health Plan Premier (HMO)
Premium and Benefits |
Ochsner Health Plan Premier (HMO) |
What You Should Know |
---|---|---|
Monthly Plan Premium |
You pay $0 |
You must also continue to pay your Medicare Part B premium. |
Part B Premium Reduction; |
Up to $30 |
|
Annual Medical Deductible |
$0 |
There is no medical deductible. |
Maximum Out-of-Pocket Responsibility (does not include prescription drugs) |
$3,500 annually |
This amount is the most you will have to pay for copays, coinsurance, and other costs for medical services during the year |
Inpatient Hospital |
$65 copayment each day for $0 copayment for You pay these amounts until you |
Our plan covers an unlimited number of days for inpatient hospital stays. Your provider may need to obtain prior authorization. |
Outpatient Hospital | ||
|
$125 copay |
Your provider may need to obtain prior authorization. |
|
$125 copay |
|
|
$0 copay | |
Doctor Visits | ||
|
$0 copay |
|
|
$20 copay | |
Preventive Care (e.g. flu vaccine, COVID-19 vaccine, diabetic screenings, etc.) |
$0 copay | Any additional preventive services approved by Medicare during the contract year will be covered. |
Emergency Care (local and world-wide) | $90 copay | If you are admitted to the hospital within one day, the emergency room copay is waived. |
Urgently Needed Services (local and world-wide) |
$20 copay |
If you are admitted to the hospital within one day, the urgent care copay is waived. |
Premiums and Benefits |
Ochsner Health Plan Premier (HMO) |
What You Should Know |
Diagnostic Services/Labs/Imaging | ||
|
$0 copay for diagnostic mammogram |
Your provider may need to obtain prior authorization. |
|
$0 copay | |
|
$10 copay | |
|
$20 copay | |
|
$10 copay | |
Hearing Services | ||
|
$20 copay |
|
|
$10 copay | One (1) routine exam every year. |
|
$1,000 allowance every year | Plan pays up to $500 per ear each year. |
Dental Services | ||
|
$0 copay for oral exams, cleaning and x-rays. | Preventive Dental (oral exams, cleaning, dental x-ray) each service limited to 2 treatments per year. |
|
$50 deductible applies before coverage begins. $11- $295 copay for restorative services $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 $2,000 in total combined cost per year. |
Vision Services | ||
|
$20 copay |
|
|
$0 copay | |
|
$0 copay | One (1) routine exam per year |
|
$0 copay | Up to $200 every year |
Mental Health Services | ||
|
$65 copayment per day for days 1-10 of Medicare-covered hospital care. $0 copay for days 11-90 |
|
|
$20 copay | |
|
$20 copay | |
Skilled Nursing Facility (SNF) |
$0 copay per day for days 1-20 $165 copay per day 21-100 |
Our plan covers up to 100 days in a SNF. Zero (0) hospital days required prior to SNF admission. |
Therapy/Rehabilitation Services | ||
|
$10.00 copay | |
Ambulance (local and world-wide) |
$235 copay for ground ambulance 20% coinsurance for air ambulance |
Prior authorization may be required for Medicare-covered non- emergent 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 | You pay $0 copay for Medicare- covered services | Your provider may need to obtain prior authorization. |
Foot Care (Podiatry) |
$20 copay |
Limited to six (6) routine podiatry services per year |
Medical Equipment/Supplies | ||
Durable Medical Equipment (e.g. wheelchairs, oxygen, etc.) | 0% for DME from preferred provider |
Your provider may need to obtain prior authorization. |
20% for DME from other providers | ||
Prosthetics (e.g. braces, artificial limbs, etc.) | 0% for DME from preferred provider. | |
Diabetes Supplies |
$0 copay |
|
Over-the-Counter (OTC) Items | You pay $0 copay 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 | $10 copay | Manual manipulation of the spine to correct subluxation |
Diabetes Management | ||
|
$0 copay | |
Fitness Program | $0 copay | Must use network fitness facility. Program includes fitness tracker. |
Meal Benefit | $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 | $0 copay | Must be provided by a CMS certified Opioid Treatment Services Program. |
Outpatient substance abuse treatment – group or individual | $20 copay | |
Renal dialysis | 20% coinsurance | Your provider may need to obtain prior authorization. |
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 711or 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.