LAC 32:V.405. Schedule of Benefits

A. Benefits and Coinsurance 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 – 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 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 Ground Ambulance Services; In-State | 80% - 20%1 Emergency Ground Ambulance Services; Out-of-State | 80% - 20%1 Non-Emergency Ground Ambulance Services | 80% - 20%1 Emergency Room (Facility Charge) | 80% - 20%1 Emergency Medical Services (Non-Facility Charge) | 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 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) | 80% - 20%1,3 | Not Covered Hearing Impaired Interpreter Expense | 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 Visits 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 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