31.11.12.05

.05 Uniform Cost-Sharing Arrangements Specific Services.

A. Preferred Provider—Credit Fund Delivery System.

(1) Coverage of Category I Services.

(a) Except for services listed in Regulation .03A(15), (17), (18), (22), (25), and (34) of this chapter, Category I services shall be covered as follows:

(i) Payment for covered services by the fund;

(ii) After exhaustion of the fund and after meeting the deductible requirement as described in Regulation .04B(3) of this chapter, coinsurance requirements as described in Regulation .04B(4) of this chapter.

(b) In addition to the deductible and coinsurance requirements specified in §A(1)(a)(ii) of this regulation, services listed in Regulation .03A(17) and (18) of this chapter are subject to a combined benefit maximum of $1,000 per person per contract year.

(c) In addition to the deductible and coinsurance requirements specified in §A(1)(a)(ii) of this regulation, services listed in Regulation .03A(15), (22), (25), and (34) of this chapter are subject to a benefit maximum of $1,000 per person per contract year.

(2) Coverage of Category II Services.

(a) Except for emergency services, Category II services shall be covered by meeting the deductible requirement as described in Regulation .04B(3) of this chapter and coinsurance requirements as described in Regulation .04B(4) of this chapter.

(b) After meeting the deductible requirement as described in Regulation .04B(3) of this chapter, emergency services shall be subject to a $100 copay in addition to the coinsurance requirements as described in Regulation .04B(4) of this chapter.

(3) Coverage of Category III Services.

(a) Except as required in §A(3)(d) of this regulation, each covered person shall pay the lesser of the cost of the prescription or a copayment of $15.

(b) Coverage for brand name drugs covered through a pharmacy discount card shall require coinsurance by the covered person of 100 percent of the discounted rate.

(c) Category III services for generic drugs shall be subject to a $500 benefit maximum per contract year for each covered person.

(d) Each covered person shall pay the lesser of the cost of the prescription or a $30 copayment for a 90-day supply of generic maintenance drugs dispensed in a single dispensing of a prescription.

(e) Coverage of up to a 90-day supply of maintenance drugs in a single dispensing is not required for the first prescription of a maintenance drug or a change in a prescription of a maintenance drug.

B. Preferred Provider—Capped Benefit Delivery System.

(1) Group A services are divided into the following services categories:

(a) Physician and other health care practitioner office visits (non-preventive services);

(b) Physician and other health care practitioner office visits (preventive services);

(c) Equipment and supplies;

(d) Inpatient physician and other non-facility services; and

(e) Outpatient physician and other health care practitioner services.

(2) The following benefit maximums apply to the Group A service category indicated:

(a) $200 per covered person per contract year for physician and other health care practitioner office visits (nonpreventive services), as listed in Regulation .03A(1), (17), (18), (20), (23), (24), and (29) of this chapter;

(b) $150 per covered person per contract year for physician and other health care practitioner office visits (preventive services), as listed in Regulation .03A(9)—(12), (31), (33), and (35) of this chapter;

(c) $250 per covered person per contract year for equipment and supplies, as listed in Regulation .03A(15), (22), (25), and (34) of this chapter;

$700 per covered person per contract year for inpatient physician and other nonfacility services, as listed in Regulation .03A(2)(a), (4)(a), (7)(a), (13), (14)(a), (19)(a), (21)(a), (26)(a), (28)(a), and (30)(a) of this chapter; and

(e) $500 per covered person per contract year for outpatient physician and other health care practitioner services, as listed in Regulation .03A(3)(a) and (5)(a) of this chapter.

(3) The following benefit maximums apply to the Group B service category indicated:

(a) $200 per covered person per contract year for emergency and ambulance services, as listed in Regulations .03A(6) and (8) of this chapter; and

(b) $150 per covered person per contract year for outpatient laboratory and diagnostic services, as listed in Regulation .03A(16) of this chapter.

(4) Services covered under Group F shall be covered as follows:

(a) Except as required in §B(4)(b) of this regulation, each covered person shall pay the lesser of the cost of the prescription or a copayment of:

(i) $10 for generic drugs;

(ii) $30 for preferred brand-name drugs; or

(iii) $50 for nonpreferred brand-name drugs;

(b) Each covered person shall pay the lesser of the cost of the prescription or a copayment for a 90-day supply of maintenance drugs dispensed in a single dispensing of a prescription as follows:

(i) For generic maintenance drugs, one $20 copayment;

(ii) For preferred brand-name maintenance drugs, one $60 copayment; or

(iii) For nonpreferred brand-name maintenance drugs, one $100 copayment;

(c) Coverage of up to a 90-day supply of maintenance drugs in a single dispensing is not required for the first prescription of a maintenance drug or a change in a prescription of a maintenance drug; and

(d) Services covered in Group F shall be subject to a maximum benefit per contract year of:

(i) $250 for a person enrolled under individual coverage; and

(ii) $750 for a person enrolled under other than individual coverage.