LAC 32:V.205. Schedule of Benefits

A. Benefits and Coinsurance 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 - 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 Bariatric Surgery Services – Facility Services4 | $2,500.00 Copayment2,3 | Not Covered | Non-Network Providers Not Covered Bariatric Surgery Services – Professional Services4 | 90% - 10%2,3 | Not Covered | Network Providers 90% - 10%2,3 Bariatric Surgery Services – Professional Services4 | 90% - 10%2,3 | Not Covered | 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 Bariatric Surgery Services – Preoperative and Postoperative Medical Services4 | 80% - 20%2,3 | Not Covered | 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% Birth Control Devices - Insertion and Removal (as listed in the Preventive and Wellness Care Article in the Benefit Plan) | 100% - 0% | 70% - 30%1 | 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 | 80% - 20%1 Emergency Ground Ambulance Services; Out-of-State | 90% - 10%1 | 70% - 30%1 | 80% - 20%1 Non-Emergency Ground Ambulance Services | 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 | 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% 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% 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 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 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 | 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.