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. $3.30
Behavioral Health - Medical Office Visit (Psychiatrist or Nurse Practitioner only) Covered Psychiatrist or Nurse Practitioner only. $3.30
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.
Preventive and Rehabilitative Services for Primary Care Enhancements (adults & children) Covered Combined total of 105 hours (420 units) per year (July 1st - June 30th). $0
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).