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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 Acadiana Area. 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 $30.00. 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 $3700.00 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 different copays or coinsurance amounts depending on the drug tier and pharmacy you use. For example, preferred generic drugs have no copay, while standard generic drugs have a $45 copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you will pay nothing for covered drugs. This plan's premium may be reduced if you qualify for the low-income subsidy.
Additional Benefits
The Ochsner Health Plan Premier (HMO) offers a range of benefits, including inpatient hospital stays with a copay, outpatient services with varying copays, and coverage for emergency services. The plan also includes primary care, preventive, hearing, vision, and dental services, with some services having no copay and others with copays or coinsurance. Additional benefits include home health services with no copay, skilled nursing facility care with a copay after 20 days, and coverage for medical equipment and home infusion services. The plan also offers over-the-counter item coverage and meal benefits for chronic illness, but excludes some services like podiatry, certain hearing aids, and specific vision and dental procedures.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric care, are covered. For days 1-10, there is a $115 copay, and for days 11-90, there is no copay.
Outpatient Services See details
Outpatient Services includes coverage for all outpatient hospital services, with a copay between $0 and $150, Ambulatory Surgical Center (ASC) Services with no copay, and outpatient substance abuse services with a $20 copay for both individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Ochsner Health Plan Premier (HMO) with a $40 copay; prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered. Ground ambulance services have a $235 copay, and air ambulance services have 20% coinsurance. 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, and Urgently Needed Services has a $35 copay; Worldwide Emergency Transportation has a $235 copay and 20% coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have copays of $140 and $35, respectively.
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, and physical therapy and speech-language pathology services with a $20 copay. Mental health specialty services, other health care professional, and psychiatric services are covered, with individual and group sessions for each having a $25 copay. Podiatry services are not covered. Additional telehealth benefits and opioid treatment program services are also covered.
Preventive Services See details
The Ochsner Health Plan Premier (HMO) plan covers preventive services, including annual physical exams, with no copay. Additional preventive services like Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), and others are not covered. The plan also covers Kidney Disease Education Services with prior authorization and other preventive services like Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit.
Hearing Services See details
Hearing Services include routine hearing exams with a $20 copay, fitting/evaluation for hearing aids, and prescription hearing aids (all types) with a limit of two visits per year; however, prescription hearing aids - inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Ochsner Health Plan Premier (HMO) covers vision services, including routine eye exams with a $20 copay. Eyewear benefits are covered, including contact lenses and eyeglasses (lenses and frames), but 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, and other dental services including oral exams, dental x-rays, prophylaxis (cleaning), restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable), and oral and maxillofacial surgery, each with a 25% coinsurance. Fluoride treatments, maxillofacial prosthetics, implant services, prosthodontics (fixed), and orthodontics are not covered. Orthodontic Services have a maximum plan benefit of $3,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered, with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Ochsner Health Plan Premier (HMO) with prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, Prosthetics/Medical Supplies with a 20% coinsurance, and Diabetic Equipment, including Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts, each with a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Ochsner Health Plan Premier (HMO). Diagnostic Procedures/Tests have a $10 copay, while Lab Services have no copay. Diagnostic Radiological Services have a copay of up to $125, Therapeutic Radiological Services have a copay of up to $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 require authorization. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically 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 under the Ochsner Health Plan Premier (HMO), but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $165 per day.
Other Services See details
The Ochsner Health Plan Premier (HMO) plan's other services benefit includes coverage for over-the-counter items with a maximum benefit of $90 every three months, and meal benefits for a chronic illness with prior authorization and a doctor referral required, however, acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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