2024 Classic (HMO-POS) Plan H6453-013-4 - $0 per month


HMO-POS plan available in ASCENSION, ASSUMPTION, EAST BATON ROUGE, EAST FELICIANA, IBERVILLE, JEFFERSON, LAFOURCHE, LIVINGSTON, ORLEANS, PLAQUEMINES, POINTE COUPEE, ST. BERNARD, ST. CHARLES, ST. HELENA, ST. JAMES, ST. JOHN THE BAPTIST, TERREBONNE, WEST BATON ROUGE, WEST FELICIANA parishes.

 $0 premium

 $1,980 on a Flex Card to pay for out-of-pocket costs, including:

  •  $1,100 to pay for prescription hearing aids

  •  $400 to pay for eyewear like eyeglasses and contact lenses from your choice of hundreds of participating providers and retailers

  •  $480 ($120 available per quarter) for over-the-counter health-related products that you can purchase at major retailers or online

 $0 deductible for in-network medical services

 $0 copay for in-network primary care provider visits

 $0 deductible for prescription drugs

 $0 copay for up to a three-month supply of Tier 1 generics at preferred retail pharmacies and by preferred mail order

 See a specialist without a referral

 Dental, vision, hearing, fitness center membership

 HMO-POS plan includes a network of providers with a point-of-service option that allows care outside of the network (certain restrictions apply)


In-Network Medical
& Hospital Benefits

  HMO-POS
Premium $0 Per Month
Medical Deductible $0 Per Year
Preventive Care $0 Copay
Primary Care Visits $0 Copay
Specialist Visits $35 Copay
Urgent Care $40 Copay
Emergency Room Care $90 Copay
Inpatient Hospital Care $125 Per Day for Days 1-10; $0 Per Day for Days 11-90 (per admit)
Outpatient Hospital Surgery $250 Copay
Maximum Out-of-Pocket Limit $5,900 Per Year

Classic (HMO-POS) Prescription Drug Benefits*

Deductible $0 prescription drug deductible
Preferred Retail and Mail-Order Cost-Sharing
Tier One-Month Supply Two-Month Supply Three-Month Supply
Tier 1 (Preferred Generics) $0 copay $0 copay $0 copay
Tier 2 (Generics) $12 copay $24 copay $36 copay
Tier 3 (Preferred Brand)** $45 copay $90 copay $135 copay
Tier 4 (Non-Preferred Drug) $100 copay $200 copay $300 copay
Tier 5 (Specialty) 33% coinsurance Not offered Not offered
Standard Retail and Mail-Order Cost-Sharing
Tier One-Month Supply Two-Month Supply Three-Month Supply
Tier 1 (Preferred Generics) $8 copay $16 copay $24 copay
Tier 2 (Generics) $16 copay $32 copay $48 copay
Tier 3 (Preferred Brand)** $47 copay $94 copay $141 copay
Tier 4 (Non-Preferred Drug) $100 copay $200 copay $300 copay
Tier 5 (Specialty) 33% coinsurance Not offered Not offered

*For in-network pharmacies only.
**Some generics may be included on Tier 3.

Plan Features to Help Keep You Healthy
(HMO-POS)*

Flex Card $1,980 on a Flex Card to pay for out-of-pocket costs, including:
  • $1,100 to pay for prescription hearing aids
  • $400 to pay for eyewear like eyeglasses and contact lenses from your choice of hundreds of participating providers and retailers
  • $480 ($120 available per quarter) for over-the-counter health-related products that you can purchase at major retailers or online
Dental Services Dental benefits including two dental cleanings and two exams per year covered at no cost (total allowance of $2,000 combined preventive and comprehensive dental services). Can use allowance amount toward dentures.
Vision Services No-cost routine eye exam (up to 1 every year) with the freedom to choose from hundreds of participating providers and retailers, plus $400 to spend on eyewear via Flex Card
Hearing Services $0 copay for routine hearing exam (up to 1 every year), plus $1,100 to spend on prescription hearing aids via Flex Card
Fitness Benefit No-cost fitness center membership or home fitness kits
Over-the-Counter Health-Related Products $480 ($120 available per quarter) via Flex Card for over-the-counter health-related products that you can purchase at major retailers or online

* For in-network services only, where applicable. Retailer restrictions may apply.

The Silver&Fit Program is provided by American Specialty Health Fitness Inc., a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a registered trademark of ASH and used with permission herein. All programs and services are not available in all areas.


2024 Classic (HMO-POS) Plan H6453-013-4 Documents:


The benefit information provided is a brief summary, not a complete description of benefits. Premiums and copayments/coinsurance amounts may change on January 1 of each year.
If you would like to speak with an agent or request a free kit, please call us toll free at 1-800-232-4967 (TTY 711) 7 days a week from 8 a.m. – 8 p.m.