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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.




Prior approval required. Abortions are covered only when there is written physician certification of the need for the abortion.N/A


CoveredAges 18 and younger. Limits apply.$0
Acupuncture & Biofeedback ServiceNot CoveredN/AN/A
Ambulance - Emergency and Non-EmergencyCoveredMust be medically necessary.$0
Ambulatory Surgical CenterCoveredCopay is applied per day.$3.30
Autism ASD Treatment ServicesCoveredNone.$0
Audiology ServicesCoveredAges 20 and younger.$0
Bariatric Surgery - Surgery for Morbid ObesityCoveredOnly if medically necessary.$0
Behavioral Health - Including Screenings (Inpatient)CoveredPrior approval required.$25.00
Behavioral Health - Psychiatric Diagnostic Evaluation (Outpatient)Covered1 evaluation every 6 months.$0
Behavioral Health - Medical Office Visit (Psychiatrist or Nurse Practitioner only)CoveredPsychiatrist or Nurse Practitioner only.$0
Biopharmaceuticals (specialty injectables)CoveredPrior approval required.$0
Cardiac RehabCoveredNone.$0
Chiropractic ServicesCovered1 per day/6 per year.$0
CircumcisionCoveredCovered during the initial newborn stay and up to 180 days after delivery in the office setting. Otherwise prior approval required.$0
Clinic VisitsCoveredNone.$0
Cosmetic SurgeryNot CoveredN/AN/A
Dermatology ServicesCoveredCosmetic is not covered.$0
Dental ServicesCoveredCovered by SCDHHS/DentaQuest.N/A
Developmental Evaluation ServicesCoveredCovered for members between the ages of 0 and 21.$0
Diabetic ShoesCovered1 pair per year (3 inserts per year).$0
Diabetic SuppliesCoveredPrior approval may be required.$3.40
Diabetic EducationCoveredNone.$0
Durable Medical Equipment (DME) - including, but not limited to: rental equipment, wheelchairs, ventilators, oxygen, monitors, lifts, nebulizers, bili-blankets, etc.CoveredPrior approval may be required for some equipment.$0
Emergency Care (in-network and out-of-network)CoveredNone.$0
Emergency TransportationCoveredNone.$0
Enteral/Parenteral Nutrition TherapyCoveredIf provided via tube and sole source of nutrition.$0
Family Planning ServicesCoveredSelf-referrals; in- and out-of-network providers covered by Absolute Total Care.$0
Fluoride Rinse/VarnishCoveredAs a part of EPSDT only.$0
Genetic TestingCoveredPrior approval required.$0
Hearing Tests, Aids & DevicesCoveredAges 20 and younger. Prior approval required.$0
Home Health CareCoveredPrior approval required. 50 visits per year (July 1st - June 30th).$0
Home Infusion TherapyCoveredPrior approval may be required for certain medications.$0
Hospice CareCovered by SCDHHSN/AN/A
HysterectomyCoveredPrior approval and completed Consent for Sterilization form (Form HHS-687) required.$0
Infertility ServicesNot CoveredN/AN/A
Inpatient Medical/Surgical ServicesCoveredPrior approval required.$25.00
Inpatient Rehabilitation ServicesCoveredPrior approval required.$25.00
Insulin PumpsCoveredPrior approval required. Not covered for Type II diabetics.$0
Laboratory ServicesCoveredNone.$0
Long-Term Care FacilityCoveredPrior approval required. SCDHHS CLTC certification (Form 185) must be completed prior to admission.  Absolute Total Care covers first 90 days only.$0
Maternity ServicesCoveredOB/GYN visits, etc.$0
Medical TransportationCovered by SCDHHSN/AN/A
Non-participating ProvidersCoveredMust be medically necessary and service not available in-network.Varies
OB UntrasoundsCoveredMaternal Fetal Medicine Provider - No limitation. All Other Providers - 3 ultrasounds per pregnancy.$0
Office Visits (PCP/Specialists) (Well & Sick Visits)CoveredNone.$0
Orthotics & ProstheticsCoveredPrior approval may be required.$0
Outpatient Hospital (non-emergency)CoveredPrior approval may be required.$3.40
Outpatient SurgeryCoveredPrior approval may be requried.$3.40
Pain Management ServicesCoveredPrior approval may be required.$0
Podiatry ServicesCoveredAges 21 and younger may have services performed by PCP/Podiatrist. Ages 22 and older must be diabetic to receive.$0
Power WheelchairsCoveredEvery 7 years, limited accessories covered. Prior approval required.$0
PrescriptionsCoveredNone.$3.40 begins at age 19. $0 copay for select medications on the PDL for asthma, COPD, smoking cessation, and diabetes.
Pulmonary RehabCoveredNone.$0
Reversal of SterilizationNot CoveredN/AN/A
Smoking Cessation ProductsCoveredQuantity per Preferred Drug List (PDL).$0 copay for smoking cessation medications on PDL.
SterilizationCoveredComplete Consent for Sterilization form (Form HHS-687) requred.$0
Rehabilitative Therapies for Children, Non-Hospital BasedCoveredAges 20 and younger, combined total of 105 hours (420 units) per year (July 1st - June 30th).$0
TransplantsCoveredCorneal 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)CoveredOnly if medically necessary.$0
Vaccines/Immunizations (children)CoveredAges 21 and younger.$0
Vision - Routine Screening (children)CoveredAges 20 and younger. 1 pair of glasses every 12 months. 1 replacement set every 12 months.$0
X-Ray/Radiology ServicesCoveredPrior 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).