Copays
The table below lists the Absolute Total Care copayment schedule. Copayments for healthcare services or prescription drugs are paid to the healthcare provider at the time of service. For a complete list of services or questions regarding a specific service or copay please contact Member Services at 1-866-433-6041 (TTY: 711).
There are no copays for children under 19 years old, pregnant women and institutionalized individuals (such as a nursing facility). There are no copayments for preventive care such as well-child or well-baby visits or vaccines.
| Benefit | Coverage | Limits | Copay |
|---|---|---|---|
Abortion |
Covered |
Prior approval required. Abortions are covered only when there is written physician certification of the need for the abortion. | N/A |
Acne |
Covered | Ages 18 and younger. Limits apply. | $0 |
| Acupuncture & Biofeedback Service | Not Covered | N/A | N/A |
| Ambulance - Emergency and Non-Emergency | Covered | Must be medically necessary. | $0 |
| Ambulatory Surgical Center | Covered | Copay is applied per day. | $3.30 |
| Autism ASD Treatment Services | Covered | None. | $0 |
| Audiology Services | Covered | Ages 20 and younger. | $0 |
| Bariatric Surgery - Surgery for Morbid Obesity | Covered | Only if medically necessary. | $0 |
| Behavioral Health - Including Screenings (Inpatient) | Covered | Prior approval required. | $25.00 |
| Behavioral Health - Psychiatric Diagnostic Evaluation (Outpatient) | Covered | 1 evaluation every 6 months. | $0 |
| Behavioral Health - Medical Office Visit (Psychiatrist or Nurse Practitioner only) | Covered | Psychiatrist or Nurse Practitioner only. | $0 |
| Biopharmaceuticals (specialty injectables) | Covered | Prior approval required. | $0 |
| Cardiac Rehab | Covered | None. | $0 |
| Chemotherapy | Covered | None. | $0 |
| Chiropractic Services | Covered | 1 per day/6 per year. | $0 |
| Circumcision | Covered | Covered during the initial newborn stay and up to 180 days after delivery in the office setting. Otherwise prior approval required. | $0 |
| Clinic Visits | Covered | None. | $0 |
| Cosmetic Surgery | Not Covered | N/A | N/A |
| Dermatology Services | Covered | Cosmetic is not covered. | $0 |
| Dental Services | Covered | Covered by SCDHHS/DentaQuest. | N/A |
| Developmental Evaluation Services | Covered | Covered for members between the ages of 0 and 21. | $0 |
| Diabetic Shoes | Covered | 1 pair per year (3 inserts per year). | $0 |
| Diabetic Supplies | Covered | Prior approval may be required. | $3.40 |
| Diabetic Education | Covered | None. | $0 |
| Dialysis | Covered | None. | $0 |
| Durable Medical Equipment (DME) - including, but not limited to: rental equipment, wheelchairs, ventilators, oxygen, monitors, lifts, nebulizers, bili-blankets, etc. | Covered | Prior approval may be required for some equipment. | $0 |
| Emergency Care (in-network and out-of-network) | Covered | None. | $0 |
| Emergency Transportation | Covered | None. | $0 |
| Enteral/Parenteral Nutrition Therapy | Covered | If provided via tube and sole source of nutrition. | $0 |
| Family Planning Services | Covered | Self-referrals; in- and out-of-network providers covered by Absolute Total Care. | $0 |
| Fluoride Rinse/Varnish | Covered | As a part of EPSDT only. | $0 |
| Genetic Testing | Covered | Prior approval required. | $0 |
| Hearing Tests, Aids & Devices | Covered | Ages 20 and younger. Prior approval required. | $0 |
| Home Health Care | Covered | Prior approval required. 50 visits per year (July 1st - June 30th). | $0 |
| Home Infusion Therapy | Covered | Prior approval may be required for certain medications. | $0 |
| Hospice Care | Covered by SCDHHS | N/A | N/A |
| Hysterectomy | Covered | Prior approval and completed Consent for Sterilization form (Form HHS-687) required. | $0 |
| Infertility Services | Not Covered | N/A | N/A |
| Inpatient Medical/Surgical Services | Covered | Prior approval required. | $25.00 |
| Inpatient Rehabilitation Services | Covered | Prior approval required. | $25.00 |
| Insulin Pumps | Covered | Prior approval required. Not covered for Type II diabetics. | $0 |
| Laboratory Services | Covered | None. | $0 |
| Long-Term Care Facility | Covered | Prior approval required. SCDHHS CLTC certification (Form 185) must be completed prior to admission. Absolute Total Care covers first 90 days only. | $0 |
| Maternity Services | Covered | OB/GYN visits, etc. | $0 |
| Medical Transportation | Covered by SCDHHS | N/A | N/A |
| Non-participating Providers | Covered | Must be medically necessary and service not available in-network. | Varies |
| OB Untrasounds | Covered | Maternal Fetal Medicine Provider - No limitation. All Other Providers - 3 ultrasounds per pregnancy. | $0 |
| Office Visits (PCP/Specialists) (Well & Sick Visits) | Covered | None. | $0 |
| Orthotics & Prosthetics | Covered | Prior approval may be required. | $0 |
| Outpatient Hospital (non-emergency) | Covered | Prior approval may be required. | $3.40 |
| Outpatient Surgery | Covered | Prior approval may be requried. | $3.40 |
| Pain Management Services | Covered | Prior approval may be required. | $0 |
| Podiatry Services | Covered | Ages 21 and younger may have services performed by PCP/Podiatrist. Ages 22 and older must be diabetic to receive. | $0 |
| Power Wheelchairs | Covered | Every 7 years, limited accessories covered. Prior approval required. | $0 |
| Prescriptions | Covered | None. | $3.40 begins at age 19. $0 copay for select medications on the PDL for asthma, COPD, smoking cessation, and diabetes. |
| Pulmonary Rehab | Covered | None. | $0 |
| Reversal of Sterilization | Not Covered | N/A | N/A |
| Smoking Cessation Products | Covered | Quantity per Preferred Drug List (PDL). | $0 copay for smoking cessation medications on PDL. |
| Sterilization | Covered | Complete Consent for Sterilization form (Form HHS-687) requred. | $0 |
| Rehabilitative Therapies for Children, Non-Hospital Based | Covered | Ages 20 and younger, combined total of 105 hours (420 units) per year (July 1st - June 30th). | $0 |
| Transplants | Covered | Corneal transplants are covered. Pre- and post- transplant services are covered for other transplants covered by Medicaid Fee-for-Service when coordinated by Absolute Total Care. | $0 |
| Vaccines/Immunizations (adult) | Covered | Only if medically necessary. | $0 |
| Vaccines/Immunizations (children) | Covered | Ages 21 and younger. | $0 |
| Vision - Routine Screening (children) | Covered | Ages 20 and younger. 1 pair of glasses every 12 months. 1 replacement set every 12 months. | $0 |
| X-Ray/Radiology Services | Covered | Prior approval required for certain services. | $0 |
State Covered Services
Absolute Total Care does not cover all of your services. Some services are covered by Medicaid Fee-for-Service and are called “carved-out benefits.”
State covered services include:
- Routine and emergency dental services – DentaQuest: 1-888-307-6553
- Long-term institutional care for stays over 90 days
- Hospice care
- Transplants (other than corneal transplants)
For a complete list of services provided by either Absolute Total Care or Medicaid Fee-for-Service please contact Member Services at 1-866-433-6041 (TTY: 711).