La. Admin. Code tit. 32 § III-107
Copayments and Coinsurance | ||
Network Providers | Non-Network Providers | |
Physician Office Visits * 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 - Ground (for Emergency Medical Transportation only) | $50 Copayment | $50 Copayment |
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 36 visits 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 |
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 - Ortho-Mammary Surgical (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. | ||
La. Admin. Code tit. 32, § III-107