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Ochsner Health Plan Premier (HMO)

The Premier Plan requires you to use a specific network of doctors, hospitals, pharmacies and other providers. Using providers from this network (called “in-network”) ensures the plan will help you pay for the cost of care and services. If you use providers that aren’t in the network (called “out-of-network"), the plan might deny coverage and you may end up paying the entire cost of your treatment or services. 

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

Premium and Benefit Detail

This is a summary of drug and health services covered by Ochsner Health Plan Premier (HMO), Jan. 1, 2022 - Dec. 31, 2022.

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 copay per day, for days 1 to 10 of Medicare-covered hospital care. 

$0 copay for additional Medicare-covered days.  

You pay these amounts until you 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.

Outpatient Hospital
  • Ambulatory Surgery Center 

$125 copay
$0 copay for diagnostic colonoscopy 
$125 copay

Your provider may need to obtain prior authorization. 
 
  • Outpatient Hospital Including  Surgery 
$0 copay for diagnostic colonoscopy 
  • Outpatient Observation Services
$0 copay 
Doctor Visits 
  • Primary Care 

$0 copay

 
  • Specialist Care 
$20 copay 

Preventive Care (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  $90 copay (worldwide)  If you are admitted to the hospital within one day, the emergency room copay is waived. 

Urgently Needed Services

$20 copay (worldwide)

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 
  • Diagnostic Radiology Services (MRI, etc.)

$0 copay for diagnostic mammogram 
20 copay for other services 

Your provider may need to obtain prior authorization.
  • Lab Services
$0 copay
  • Diagnostic Tests and   Procedures
$10 copay 
  • Therapeutic Radiology
$20 copay 
  • Outpatient X-Ray
$10 copay   
Hearing Services 
  • Exam to diagnose and treat hearing and balance issues

$20 copay 

 
  • Routine Hearing Exam
$10 copay One routine exam every year. 
  • Hearing Aids 
$1000 allowance every year  Plan pays up to $500 per ear each year. 
Dental Services
  • Medicare Covered 

$20 copay

Medicare-covered Benefits limited to services provided under the Medicare program.  

  • Preventive Dental
$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.
  • Comprehensive Dental 

$50 deductible applies before coverage begins $0 - $217.75 copay for comprehensive dental services 

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. 

Vision Services
  • Exam to diagnose and treat eye conditions and eye diseases

$20 copay

 
  • Eyewear post-cataract surgery
$0 copay  
  • Routine Eye Exam
$0 copay 1 routine exam per year
  • Eyewear 
$0 copay Up to $200 every year 
Mental Health Services 
  • Inpatient visit 

 

$65 copayment per day for days 1-10 of Medicare-covered hospital care. $0 copayment for additional Medicare-covered days.  

 
  • Outpatient Group Therapy Visit 
$20 copay   
  • Outpatient Individual Therapy Visit 
$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. 

0 hospital days required prior to SNF admission. 

Rehabilitative Services 
  • Occupational Therapy Visit 
$10.00   
  • Physical Therapy and Speech and Language Therapy Visit

$10.00   
Ambulance 

$235 copay for ground ambulance 

20% coinsurance for air ambulance 

Prior authorization may be required for Medicare-covered non- emergent   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 in excess of $250. 
Home Health Services  $0 copay for Medicare-covered services  Prior Authorization required. 
Foot Care (Podiatry) 

$20 copay 

Limited to 6 routine podiatry services per year 
Medical Equipment/Supplies 
  • Durable Medical Equipment (wheelchairs, oxygen, etc.) 

  • Prosthetics (braces, artificial limbs, etc.) 

0% for DME from preferred  provider. 

Prior authorization is required for billed charges in excess of 

$250. 

  • Diabetes Supplies 
20% for DME from other providers.   
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 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  $10 copay  Includes manual manipulation of the spine to correct subluxation. 
Diabetes Management 
  • Diabetes Monitoring Supplies 
$0 copay  
  • Diabetes Self-management Training 
$0 copay  
  • Therapeutic Shoes or inserts 
$0 copay  
Health Education  $0 copay Get help over the phone from a clinical team who can help you manage chronic conditions. 
Fitness Program  $0 copay Must use an in-network fitness facility. 
Meal Benefit  $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  $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  

 

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.