La. Admin. Code tit. 32 § V-205
Coinsurance | |||
Active Employees/ Non-Medicare Retirees (regardless of retire date) | Retirees with Medicare (regardless of retire date) | ||
Network Providers | Non-Network | Network Providers | |
Physician Office Visits including surgery performed in an office setting: * General Practice * Family Practice * Internal Medicine * OB/GYN * Pediatrics | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Allied Health/Other Professional Visits: * Chiropractors * Federally Funded Qualified Rural Health Clinics * Nurse Practitioners * Retail Health Clinics * Physician Assistants | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Specialist (Physician) Office Visits including surgery performed in an office setting: * Physician * Podiatrist * Optometrist * Midwife * Audiologist * Registered Dietician * Sleep Disorder Clinic | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Ambulance Services - Ground (for Emergency Medical Transportation only) | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Ambulance Services - Air (for Emergency Medical Transportation only) Non-emergency requires prior authorization2 | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Ambulatory Surgical Center and Outpatient Surgical Facility | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Bariatric Surgery Services - Facility Services4 | $2,500.00 Copayment2,3 | Not Covered | Network Providers $2,500.00 Copayment2,3 |
Non-Network Providers Not Covered | |||
Bariatric Surgery Services - Professional Services4 | 90% - 10%2,3 | Not Covered | Network Providers 90% - 10%2,3 |
Non-Network Providers Not Covered | |||
Bariatric Surgery Services - Preoperative and Postoperative Medical Services4 | 80% - 20%2,3 | Not Covered | Network Providers 80% - 20%2,3 |
Non-Network Providers Not Covered | |||
Birth Control Devices -Insertion and Removal (as listed in the Preventive and Wellness Care Article in the Benefit Plan) | 100% - 0% | 70% - 30%1 | Network Providers 100% - 0% |
Non-Network Providers 80% - 20%1 | |||
Cardiac Rehabilitation (limit of 36 visits per Plan Year) | 90% - 10%1,2 | 70% - 30%1,2 | 80% - 20%12 |
Chemotherapy/Radiation Therapy (Authorization not required when performed in Physician's office) | 90% - 10%1,2 | 70% - 30%1,2 | 80% - 20%1,2 |
Diabetes Treatment | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Diabetic/Nutritional Counseling - Clinics and Outpatient Facilities | 90% - 10%1 | Not Covered | 80% - 20%1 |
Dialysis | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Durable Medical Equipment (DME), Prosthetic Appliances and Orthotic Devices | 90% - 10%1,2 | 70% - 30%1,2 | 80% - 20%1,2 |
Emergency Ground Ambulance Services; In-State | 90% - 10%1 | 90% - 10%1 | 80% - 20%1 |
Emergency Ground Ambulance Services; Out-of-State | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Emergency Room (Facility Charge) | $200 Copayment1; Waived if admitted to the same facility | ||
Emergency Medical Services (Non-Facility Charges) | 90% - 10%1 | 90% - 10%1 | 80% - 20%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 | ||
Flu shots and H1N1 vaccines (administered at Network Providers, Non-Network Providers, Pharmacy, Job Site or Health Fair) | 100% - 0% | 100% - 0% | 100% - 0% |
Hearing Aids (Hearing Aids are not covered for individuals age eighteen (18) and older) | 90% - 10%1,3 | 70% - 30%1,3 | 80% - 20%1,3 |
Hearing Impaired Interpreter Expense | 100% - 0% | 100% - 0% | 100% - 0% |
High-Tech Imaging -Outpatient * CT Scans * MRA/MRI * Nuclear Cardiology * PET Scans | 90% - 10%1,2 | 70% - 30%1,2 | 80% - 20%1,2 |
Home Health Care (limit of 60 Visits per Plan Year) | 90% - 10%1,2 | 70% - 30%1,2 | Not Covered |
Hospice Care (limit of 180 Days per Plan Year) | 80% - 20%1,2 | 70% - 30%1,2 | Not Covered |
Injections Received in a Physician's Office (when no other health service is received) | 90% -10%1 | 70% - 30%1 | 80% - 20%1 |
Inpatient Hospital Admission, All Inpatient Hospital Services Included Per Day Copayment Day Maximum Coinsurance | $0 Not Applicable 90% - 10%1,2 | $50 5 Days 70% - 30%1,2 | $0 Not Applicable 80% - 20%1,2 |
Inpatient and Outpatient Professional Services | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Mastectomy Bras - Ortho-Mammary Surgical (limit of three (3) per Plan Year) | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Mental Health/Substance Abuse - Inpatient Treatment and Intensive Outpatient Programs Per Day Copayment Day Maximum Coinsurance | $0 Not Applicable 90% - 10%1,2 | $50 5 Days 70% - 30%1,2 | $0 Not Applicable 80% - 20%1,2 |
Mental Health/Substance Abuse - Office Visit and Outpatient Treatment (Other than Intensive Outpatient Programs) | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Newborn - Sick, Services Excluding Facility | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Newborn - Sick, Facility Per Day Copayment Day Maximum Coinsurance | $0 Not Applicable 90% - 10%1,2 | $50 5 Days 70% - 30%1,2 | $0 Not Applicable 80% - 20%1,2 |
Non-Emergency Ground Ambulance Services | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Oral Surgery for Impacted Teeth | 90% - 10%1,2 | 70% - 30%1,2 | 80% - 20%1,2 |
Pregnancy Care - Physician Services | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
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 Care Article in the Benefit Plan.) | 100% - 0%3 | 70% - 30%1,3 | Network 100% - 03 |
Non-Network 80% - 20%1,3 | |||
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) | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Skilled Nursing Facility (limit 90 days per Plan Year) | 90% - 10%1,2 | 70% - 30%1,2 | 80% - 20%1,2 |
Sonograms and Ultrasounds (Outpatient) | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Urgent Care Center | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
Vision Care (Non-Routine) Exam | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
X-ray and Laboratory Services (low-tech imaging) | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 |
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, § V-205