LAC 32:V.305
A. Benefits, Copayments, and Coinsurance
| Copayments and Coinsurance | ||
|---|---|---|
| Network Providers | Non-Network Providers | |
| Physician Office General Practice Family Practice Internal Medicine OB/GYN Pediatrics | $25 Copayment per Visit | No Coverage |
| Allied Health/Other Professional Visits: Chiropractors Federally Funded Qualified Rural Health Clinics Nurse Practitioners Retail Health Clinics Physician Assistants | $25 Copayment per Visit | No Coverage |
| Specialist Office Visits including surgery performed in an office setting: Physician Podiatrist Optometrist Midwife Audiologist Registered Dietician Sleep Disorder Clinic | $50 Copayment per Visit | No Coverage |
| Ambulance Services - Air (for Emergency Medical Transportation only) Non-emergency requires prior authorization2 | $250 Copayment | No Coverage |
| Ambulatory Surgical Center and Outpatient Surgical Facility | $100 Copayment | No Coverage |
| Bariatric Surgery Services – Facility Services4 | $2,500.00 Copayment2,3 | No Coverage |
| Bariatric Surgery Services – Professional Services4 | 90% - 10%2,3 | No Coverage |
| Bariatric Surgery Services – Preoperative and Postoperative Medical Services4 | 80% - 20%2,3 | No Coverage |
| Birth Control Devices - Insertion and Removal (as listed in the Preventive and Wellness Article in the Benefit Plan.) | 100% - 0% | No Coverage |
| Cardiac Rehabilitation (limit of 36visits per Plan Year) | $25/$50 Copayment per day depending on Provider Type2 $50 Copayment- Outpatient Facility2 | No Coverage |
| Chemotherapy/Radiation Therapy (Authorization not required when performed in Physician’s office) | Office – $25 Copayment per Visit Outpatient Facility 100% - 0%1,2 | No Coverage |
| Diabetes Treatment | 80% - 20%1 | No Coverage |
| Diabetic/Nutritional Counseling - Clinics and Outpatient Facilities | $25 Copayment | No Coverage |
| Dialysis | 100% - 0%1 | No Coverage |
| Durable Medical Equipment (DME), Prosthetic Appliances and Orthotic Devices | 80% - 20%1,2 of first $5,000 Allowable per Plan Year; 100% - 0% of Allowable in Excess of $5,000 per Plan Year | No Coverage |
| Emergency Ground Ambulance Services; In-State | $50 Copayment | $50 Copayment |
| Emergency Ground Ambulance Services; Out-of-State | $50 Copayment | $50 Copayment |
| Non-Emergency Ground Ambulance Services | $50 Copayment | No Coverage |
| Emergency Room (Facility Charge) | $200 Copayment; Waived if admitted to the same facility | |
| Emergency Medical Services (Non-Facility Charges) | 100% - 0%1 | 100% - 0%1 |
| Eyeglass Frames and One Pair of Eyeglass Lenses or One Pair of Contact Lenses (purchased within six months following cataract surgery) | Eyeglass Frames – Limited to a Maximum Benefit of $501 | No Coverage |
| Flu shots and H1N1 vaccines (administered at Network Providers, Non-Network Providers, Pharmacy, Job Site or Health Fair) | 100% - 0% | 100% - 0% |
| Hearing Aids (Hearing Aids are not covered for individuals age eighteen (18) and older.) | 80% - 20%1,3 | No Coverage |
| Hearing Impaired Interpreter Expense | 100% - 0% | No Coverage |
| High-Tech Imaging - Outpatient CT Scans MRA/MRI Nuclear Cardiology PET Scans | $50 Copayment2 | No Coverage |
| Home Health Care (limit of 60 Visits per Plan Year) | 100% - 0%1,2 | No Coverage |
| Hospice Care (limit of 180 Days per Plan Year) | 100% - 0%1,2 | No Coverage |
| Injections Received in a Physician’s Office (when no other health service is received) | 100% - 0%1 | No Coverage |
| Inpatient Hospital Admission, All Inpatient Hospital Services Included | $100 Copayment per day2, maximum of $300 per Admission | No Coverage |
| Inpatient and Outpatient Professional Services for which a Copayment is Not Applicable | 100% - 0%1 | No Coverage |
| Mastectomy Bras (limited to three (3) per Plan Year) | 80% - 20%1 of first $5,000 Allowable per Plan Year; 100% - 0% of Allowable in Excess of $5,000 per Plan Year | No Coverage |
| Mental Health/Substance Abuse - Inpatient Treatment and Intensive Outpatient Programs | $100 Copayment per day2, maximum of $300 per Admission | No Coverage |
| Mental Health/Substance Abuse – Office Visit and Outpatient Treatment (Other than Intensive Outpatient Programs) | $25 Copayment per Visit | No Coverage |
| Newborn - Sick, Services excluding Facility | 100% - 0%1 | No Coverage |
| Newborn - Sick, Facility | $100 Copayment per day2, maximum of $300 per Admission | No Coverage |
| Oral Surgery | 100% - 0%1,2 | No Coverage |
| Pregnancy Care - Physician Services | $90 Copayment per pregnancy | No Coverage |
| Preventive Care - Services include screening to detect illness or health risks during a Physician office visit. The Covered Services are based on prevailing medical standards and may vary according to age and family history. (For a complete list of benefits, refer to the Preventive and Wellness Article in the Benefit Plan.) | 100% - 0%3 | No Coverage |
| Rehabilitation Services - Outpatient: Speech Physical/Occupational (Limited to 50 Visits combined PT/OT per Plan Year. Authorization required for visits over the combined limit of 50.) (Visit limits do not apply when services are provided for Autism Spectrum Disorders.) | $25 Copayment per Visit | No Coverage |
| Skilled Nursing Facility (limit of 90 days per Plan Year) | $100 Copayment per day2, maximum of $300 per Admission | No Coverage |
| Sonograms and Ultrasounds (Outpatient) | $50 Copayment | No Coverage |
| Urgent Care Center | $50 Copayment | No Coverage |
| Vision Care (Non-Routine) Exam | $25/$50 Copayment depending on Provider Type | No Coverage |
| X-ray and Laboratory Services (low-tech imaging) | Hospital Facility 100% - 0%1 Office or Independent Lab 100% - 0% | No Coverage |
| 1Subject to Plan Year Deductible, if applicable 2Pre-Authorization Required, if applicable. Not applicable for Medicare primary. 3Age and/or Time Restrictions Apply 4No Benefits will be payable unless Prior Authorization is obtained, including Plan Participants with Medicare as the Primary Plan. |
AUTHORITY NOTE: Promulgated in accordance with R.S. 42:801(C) and 802(B)(1).
HISTORICAL NOTE: Promulgated by the Office of the Governor, Division of Administration, Office of Group Benefits, LR 41:359 (February 2015), effective March 1, 2015, amended LR 43:2157 (November 2017), effective January 1, 2018, LR 48:2770 (November 2022), LR 49:1379 (August 2023), LR 50:781 (June 2024).