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