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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.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 $4500.00 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 a $0 deductible for prescription drugs. In the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, you'll pay a $10 copay for a preferred generic drug at a standard pharmacy. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Ochsner Health Plan Premier (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $180 copay for the first 10 days, and no copay for days 11-90, while outpatient services may have copays from $0 to $175. The plan also includes coverage for primary care, preventive, vision, and dental services, often with no or low copays. Additional benefits include coverage for hearing aids, ambulance services, and emergency services with specific copays or coinsurance amounts. This plan also provides coverage for home health, skilled nursing, and some diagnostic services. Other services include over-the-counter items and a meal benefit, while some services like cardiac rehabilitation and additional hours of care are not covered.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you pay a $180 copay for days 1-10, and no copay for days 11-90, and additional days are covered with no copay. For Inpatient Hospital Psychiatric, you pay a $180 copay for days 1-10, and no copay for days 11-90, but additional days are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $175, while ambulatory surgical center services have no copay; individual and group outpatient substance abuse sessions have a copay of $20, and outpatient blood services have a waived deductible for three pints.
Partial Hospitalization See details
Partial Hospitalization is covered by the Ochsner Health Plan Premier (HMO) with a $40 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Ochsner Health Plan Premier (HMO) plan. Ground ambulance services have a $235 copay, while air ambulance services have a 20% coinsurance; transportation services to health-related locations 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) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a $35 copay. Worldwide Emergency Transportation has a $235 copay and 20% coinsurance, while Worldwide Emergency Coverage has a $140 copay, and Worldwide Urgent Coverage has a $35 copay.
Primary Care See details
The Ochsner Health Plan Premier (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $20 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 $20 copay, and opioid treatment program services. This plan does not cover podiatry services or routine chiropractic care.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with no copay, annual physical exams, and other preventive services with no copay. Additional preventive services such as health education, in-home safety assessments, and others are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $20 copay, fitting/evaluation for hearing aids, and prescription hearing aids (all types) covered for 2 visits per year. Prescription hearing aids - inner ear, outer ear, and over the ear, and OTC hearing aids are not covered.
Vision Services See details
Ochsner Health Plan Premier (HMO) covers vision services including eye exams with a $20 copay, eyewear up to a combined maximum of $400 per year, and contact lenses and eyeglasses (lenses and frames) once 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. Other dental services include oral exams, dental x-rays, and cleaning with no copay, but 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, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Ochsner Health Plan Premier (HMO), but require prior authorization. There is a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered under the Ochsner Health Plan Premier (HMO) plan, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a coinsurance of 0% to 20%, while Prosthetic Devices, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures/tests, lab services, and outpatient X-ray services, are covered by the Ochsner Health Plan Premier (HMO). Diagnostic Procedures/Tests have a copay of $10, lab services have no copay, diagnostic radiological services have a copay up to $125, therapeutic radiological services have a copay of $80, 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 or 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 technically covered but not covered in practice, as Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Ochsner Health Plan Premier (HMO) with prior authorization required. For days 1-20, there is no copay, and for days 21-100, the copay is $165 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Other Services benefit for Ochsner Health Plan Premier (HMO) covers over-the-counter items with a maximum benefit of $90 every three months, as well as 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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