La. Admin. Code tit. 32 § V-505
Coinsurance | ||
Network Providers | Non-Network Providers | |
Physician's Office Visits including surgery performed in an office setting: * General Practice * Family Practice * Internal Medicine * OB/GYN * Pediatrics | 80% - 20%1 | 60% - 40%1 |
Allied Health/Other Office Visits: * Chiropractors * Federally Funded Qualified Rural Health Clinics * Retail Health Clinics * Nurse Practitioners * Physician's Assistants | 80% - 20%1 | 60% - 40%1 |
Specialist Office Visits including surgery performed in an office setting: * Physician * Podiatrist * Optometrist * Midwife * Audiologist * Registered Dietician * Sleep Disorder Clinic | 80% - 20%1 | 60% - 40%1 |
Ambulance Services - Ground (for Emergency Medical Transportation Only) | 80% - 20%1 | 80% - 20%1 |
Ambulance Services Air (for Emergency Medical Transportation only) Non-emergency requires prior authorization2 | 80% - 20%1 | 80% - 20%1 |
Ambulatory Surgical Center and Outpatient Surgical Facility | 80% - 20%1 | 60% - 40%1 |
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% | 60% - 40%1 |
Cardiac Rehabilitation (limited to 36 visits per Plan Year) | 80% - 20%1,2 | 60% - 40%1,2 |
Chemotherapy/Radiation Therapy (Authorization not required when performed in Physician's office) | 80% - 20%1,2 | 60% - 40%1,2 |
Diabetes Treatment | 80% - 20%1 | 60% - 40%1 |
Diabetic/Nutritional Counseling Clinics and Outpatient Facilities | 80% - 20%1 | Not Covered |
Dialysis | 80% - 20%1 | 60% - 40%1 |
Durable Medical Equipment (DME), Prosthetic Appliances and Orthotic Devices | 80% - 20%1,2 | 60% - 40%1,2 |
Emergency Room (Facility Charge) | 80% - 20%1 | 80% - 20%1 |
Emergency Medical Services (Non-Facility Charge) | 80% - 20%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 | No Coverage |
Emergency Ground Ambulance Services; In-State | 80% - 20%1 | 80% - 20%1 |
Emergency Ground Ambulance Services; Out-of-State | 80% - 20%1 | 80% - 20%1 |
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 | Not Covered |
Hearing Impaired Interpreter Expense | 100%-0% | 100%-0% |
High-Tech Imaging - Outpatient * CT Scans * MRA/MRI * Nuclear Cardiology * PET Scans | 80% - 20%1,2 | 60% - 40%1,2 |
Home Health Care (limit of 60 Visits per Plan Year) | 80% - 20%1,2 | 60% - 40%1,2 |
Hospice Care (limit of 180 Days per Plan Year) | 80% - 20%1,2 | 60% - 40%1,2 |
Injections Received in a Physician's Office (when no other health service is received) | 80% - 20%1 | 60% - 40%1 |
Inpatient Hospital Admission (all Inpatient Hospital services included) | 80% - 20%1,2 | 60% - 40%1,2 |
Inpatient and Outpatient Professional Services | 80% - 20%1 | 60% - 40%1 |
Mastectomy Bras (limited to three (3) per Plan Year) | 80% - 20%1 | 60% - 40%1 |
Mental Health/Substance Abuse -Inpatient Treatment and Intensive Outpatient Programs | 80% - 20%1,2 | 60% - 40%1,2 |
Mental Health/Substance Abuse Office Visit and Outpatient Treatment (Other than Intensive Outpatient Programs) | 80% - 20%1 | 60% - 40%1 |
Newborn - Sick, Services excluding Facility | 80% - 20%1 | 60% - 40%1 |
Newborn - Sick, Facility | 80% - 20%1,2 | 60% - 40%1,2 |
Oral Surgery | 80% - 20%1,2 | 60% - 40%1,2 |
Pregnancy Care - Physician Services | 80% - 20%1 | 60% - 40%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/Routine Care Article in the Benefit Plan.) | 100% - 0%3 | 100% - 0%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.) | 80% - 20%1 | 60% - 40%1 |
Skilled Nursing Facility (limit 90 Days per Plan Year) | 80% - 20%1,2 | 60% - 40%1,2 |
Sonograms and Ultrasounds - Outpatient | 80% - 20%1 | 60% - 40%1 |
Urgent Care Center | 80% - 20%1 | 60% - 40%1 |
Vision Care (Non-Routine) Exam | 80% - 20%1 | 60% - 40%1 |
X-Ray and Laboratory Services (low-tech imaging) | 80% - 20%1 | 60% - 40%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-505