A non-government entity
Ochsner Health Plan Premier (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Ochsner Health Plan Premier (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Ochsner Health Plan Premier (HMO) in 2025, please refer to our full plan details page.
Ochsner Health Plan Premier (HMO) is a HMO plan offered by Ochsner Clinic Foundation available for enrollment in 2025 to people living in New Orleans and Baton Rouge Areas. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Ochsner Health Plan Premier (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Ochsner Health Plan Premier (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Ochsner Health Plan Premier (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $24.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $2900.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Ochsner Health Plan Premier (HMO) has an enhanced alternative drug benefit. There is no deductible for prescription drugs. During the initial coverage phase, you will pay a copay for your prescriptions. For standard generic drugs, the copay is $10 at a standard pharmacy. For standard brand drugs, the copay is $100 at a standard pharmacy. Non-preferred drugs have a 33% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Ochsner Health Plan Premier (HMO) offers comprehensive coverage, including inpatient and outpatient hospital services with varying copays. Emergency services, including worldwide coverage, are included, along with primary care, preventive services, and home health services with no copay. This plan also provides benefits for hearing, vision, and dental services, with copays for routine exams and coverage for eyewear and dental procedures. Additionally, the plan covers services like ambulance, home infusion, and skilled nursing facilities, with specific copays or coinsurance amounts.
Inpatient Hospital See details
Inpatient Hospital coverage includes both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you'll pay a $65 copay for days 1-10, and no copay for days 11-90; additional days are covered with no copay. For Inpatient Hospital Psychiatric, you'll pay a $65 copay for days 1-10, and no copay for days 11-90; additional days and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services include outpatient hospital services with a copay between $0 and $100, observation services, ambulatory surgical center services with no copay, outpatient substance abuse services with a $25 copay for both individual and group sessions, and outpatient blood services. Prior authorization is required for most services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Ochsner Health Plan Premier (HMO) with a $25 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Ochsner Health Plan Premier (HMO). Ground ambulance services have a $235 copay, while air ambulance services have a 20% coinsurance; however, transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Ochsner Health Plan Premier (HMO). Emergency Services has a $140 copay, while Urgently Needed Services has a $35 copay. Worldwide Emergency Coverage has a $140 copay, Worldwide Urgent Coverage has a $35 copay, and Worldwide Emergency Transportation has a $235 copay and 20% coinsurance.
Primary Care See details
The Ochsner Health Plan Premier (HMO) plan covers primary care physician services, chiropractic services (with a $20 copay for routine care), occupational therapy services (with a $10 copay), physician specialist services (with a $25 copay), mental health specialty services (with a $25 copay for individual and group sessions), physical therapy and speech-language pathology services (with a $10 copay), and opioid treatment program services. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Ochsner Health Plan Premier (HMO) plan covers preventive services, including Medicare-covered preventive services, annual physical exams, and other preventive services. Some additional preventive services, such as Health Education, In-Home Safety Assessment, and Personal Emergency Response System (PERS), are not covered. Fitness Benefit is covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $25 copay, fitting/evaluation for hearing aids, and prescription hearing aids (all types), with a maximum plan benefit of $2,000 every year. Prescription hearing aids - Inner Ear, Outer Ear, and Over the Ear, as well as OTC hearing aids, are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a $25 copay, and include routine eye exams once per year. Eyewear is covered with a combined maximum of $400 per year for contact lenses and eyeglasses (lenses and frames), with one pair of contact lenses or eyeglasses (lenses and frames) covered per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Ochsner Health Plan Premier (HMO) plan covers Medicare dental services with no copay, while other dental services include oral exams, dental x-rays, and cleaning with prior authorization. Restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable), and oral and maxillofacial surgery are covered with 25% coinsurance. Fluoride treatment, maxillofacial prosthetics, implant services, prosthodontics (fixed), and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Ochsner Health Plan Premier (HMO) with prior authorization required. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment, Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. Durable Medical Equipment has a coinsurance between 0% and 20% and requires prior authorization, while Durable Medical Equipment for use outside the home is not covered. Medical Supplies and Diabetic Supplies have a 20% coinsurance, and Prosthetic Devices, Diabetic Therapeutic Shoes/Inserts also have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have a $10 copay, Lab Services have no copay, Diagnostic Radiological Services have a copay up to $100, Therapeutic Radiological Services have a copay of $80 or more, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the Ochsner Health Plan Premier (HMO), with no copay and no coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but none of the sub-services, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, are covered. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $165. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $105 every three months, and a Meal Benefit that requires prior authorization and a doctor referral. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, and several other services are not covered.
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