Services that require a copayment
Copays for Medical Assistance and General Assistance members
Medicaid members 18 years of age and older and in the Medical Assistance or General Assistance categories will have to pay a copay for prescriptions and various medical services.
Members who are under the age of 18, pregnant, or in a nursing home do not have to pay the copays.
Residents of a long-term care facility or other medical institution, including intermediate care facilities, do not pay copays.
MA recipients, regardless of age, who qualify for benefits under Title IV-B Foster Care and Title IV-E Foster Care and Adoption Assistance do not pay copays.
PCP visits never have a copay.
Medical and General Assistance recipients cannot be denied a prescription if they cannot afford a copayment. If you cannot afford your prescription copayment, please let your pharmacist know. If you have any problems getting your medication from the pharmacist, please contact Member Relations at 1-800-553-0784 or 215-849-9600 (TTY 711).
Medical Assistance copays
For the following services you will pay $5.00:
- For acupuncture, you will pay $5.00 for each visit (up to 20 visits). Members who are pregnant or under age 21 do not need to pay a copay.
For the following services you will pay $3.00:
- For inpatient hospital care (which includes both general and medical rehabilitation hospitals), you will pay $3.00 for each day you are in the hospital up to $21.00 for the stay
- For Short Procedure Unit (SPU)/Ambulatory Surgical Center (ASC) visits, you will pay $3.00 per admission or visit.
- For brand name prescription drugs, you will pay $3.00 for each prescription or refill.
For the following services, you will pay $1.00:
- For outpatient x-ray services, you will pay $1.00 for the service (not for each x-ray).
- For generic prescription drugs, you will pay $1.00 for each prescription or refill.
- For chiropractor visits, you will pay $1.00 for each visit.
You don’t have to pay a copayment for any of the following if they are part of your benefit package:
- Any services provided in an emergency
- Birth centers
- Blood and blood products
- Certain drugs for high blood pressure, cancer, diabetes, asthma, epilepsy, heart disease, psychosis, HIV/AIDS, glaucoma, depression, and anxiety, as well as anti-Parkinson agents, anti-manic agents, anti-convulsants, anti-neoplastic agents, oral contraceptives, test strips, lancets, meters, and needles
- CRNP (Certified Registered Nurse Practitioner) services
- Dental visits
- Disposable medical supplies
- Doctor's fee for x-rays, diagnostic tests, nuclear medicine or radiation therapy
- Drugs and vaccines that you get in your doctor’s office
- Family planning services
- Home health agency services
- Hospice services
- Laboratory tests
- Medical examinations for members under age 21 provided through the EPSDT program More than one of a series of specific allergy tests provided in a 24-hour period Non-emergency ambulance services
- Nurse midwife (maternity services)
- Optometrist visits
- Physician visits
- Podiatrist visits
- Portable x-ray services
- Renal dialysis services
- Rental of Durable Medical Equipment (DME)
- Skilled Nursing Facility
- Targeted case management services
- Tobacco cessation counseling services
- Waiver services