Dignity Health Plan (HMO I-SNP) is a Medicare Advantage Special Needs Plan by Dignity Health Plan.
This page features plan details for 2023 Dignity Health Plan (HMO I-SNP) H8492 – 001 – 0 available in Select Parishes in Louisiana.
IMPORTANT: This page features the 2023 version of this plan. See the 2025 version using the link below:
Dignity Health Plan (HMO I-SNP) is offered in the following locations.
Dignity Health Plan (HMO I-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Institutional |
| Conditions Covered: |
| Insurer: | Dignity Health Plan |
| Health Plan Deductible: | $226 per year for in-network services. |
| MOOP: | $8,300 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Dignity Health Plan (HMO I-SNP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $164.90 | $0.00 | $38.00 | $0.00 | $ |
Dignity Health Plan (HMO I-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $505.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Basic |
| Gap Coverage: | No |
| Formulary Link: | Formulary Link |
| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $38.00 | $43.40 | $34.80 | $26.30 | $17.70 |
After you pay your $505.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
| Drug Type | Cost Share |
|---|---|
| Generic drugs | 25% |
| Brand-name drugs | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Dignity Health Plan (HMO I-SNP) also provides the following benefits.
| In-Network: No |
| Diagnostic services: | Not covered (no limits) |
| Endodontics: | Not covered (no limits) |
| Extractions: | Not covered (no limits) |
| Non-routine services: | Not covered (no limits) |
| Periodontics: | Not covered (no limits) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered (no limits) |
| Restorative services: | Not covered (no limits) |
| Cleaning: | Not covered (no limits) |
| Dental x-ray(s): | Not covered (no limits) |
| Fluoride treatment: | Not covered (no limits) |
| Oral exam: | Not covered (no limits) |
| Diagnostic radiology services (e.g., MRI): | 20% coinsurance (authorization required) (referral required) |
| Diagnostic tests and procedures: | 20% coinsurance (authorization not required) (referral not required) |
| Lab services: | $0 copay (authorization not required) (referral not required) |
| Outpatient x-rays: | 20% coinsurance (authorization required) (referral required) |
| Primary: | 0-20% coinsurance per visit |
| Specialist: | 20% coinsurance per visit (authorization not required) (referral not required) |
| Emergency: | 20% coinsurance per visit (always covered) |
| Urgent care: | 20% coinsurance per visit (always covered) |
| Foot exams and treatment: | 20% coinsurance (authorization not required) (referral not required) |
| Routine foot care: | Not covered |
| 20% coinsurance |
| $226 per year for in-network services. |
| In-Network: No |
| Fitting/evaluation: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing aids: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing exam: | 20% coinsurance (authorization not required) (referral not required) |
| In 2023 the amounts for each benefit period are: $1,600 deductible for days 1 through 60 $400 copay per day for days 61 through 90 (authorization required) (referral not required) |
| 20% coinsurance per visit (authorization required) (referral not required) |
| $8,300 In-network |
| Diabetes supplies: | 20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
| Inpatient hospital – psychiatric: | In 2023 the amounts for each benefit period are: $1,600 deductible for days 1 through 60 $400 copay per day for days 61 through 90 (authorization required) (referral not required) |
| Outpatient group therapy visit: | 20% coinsurance (authorization not required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | 20% coinsurance (authorization not required) (referral not required) |
| Outpatient individual therapy visit: | 20% coinsurance (authorization not required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | 20% coinsurance (authorization not required) (referral not required) |
| No |
| $0 copay (authorization not required) (referral not required) |
| Occupational therapy visit: | 20% coinsurance (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | 20% coinsurance (authorization required) (referral not required) |
| In 2023 the amounts for each benefit period are: $0 copay for days 1 through 20 $200 copay per day for days 21 through 100 (authorization required) (referral not required) |
| Not covered |
| Contact lenses: | Not covered (no limits) |
| Eyeglass frames: | Not covered (no limits) |
| Eyeglass lenses: | Not covered (no limits) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Other: | Not covered (no limits) |
| Routine eye exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | Not covered |
| Not covered |
Ready to sign up for Dignity Health Plan (HMO I-SNP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Need more information on Dignity Health Plan (HMO I-SNP)? See 2025 Dignity Health Plan (HMO I-SNP) at MedicareAdvantageRX.com.
Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.
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