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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 1-877-454-8477).

Medical Assistance copays

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
  • Oxygen
  • 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