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Benefit/Service Children of Caretaker Relatives Categorically Needy Children KCHIP Children

Chiropractic Services $0 co-pay 7 visits per 12 months $0 co-pay 7 visits per 12 months $0 co-pay 7 visits per 12 months Prescription Drugs $0 co-pay $0 co-pay $1 generic $2 preferred $3 non-preferred brand prescriptions Emergency Room $0 co-pay $0 co-pay 5% coinsurance for non- emergency use Hearing Aids and Audiometric Services $0 co-pay $1,400 maximum per ear every 36 months; 1 audiologist visit per 12 months chidren under 21 ONLY $0 co-pay $1,400 maximum per ear every 36 months; 1 audiologist visit per 12 months chidren under 21 ONLY $0 co-pay $1,400 maximum per ear every 36 months; 1 audiologist visit per 12 months chidren under 21 ONLY Vision Services General ophthalmology and optmetry $0 co-pay $400 maximum on eyewear per 12 months; children under 21 ONLY $0 co-pay $400 maximum on eyewear per 12 months; children under 21 ONLY $0 co-pay $400 maximum on eyewear per 12 months; children under 21 ONLY Prosthetic Devices $0 co-pay $1,500 per 12 months $0 co-pay $1,500 per 12 months $0 co-pay $1,500 per 12 months Home Health Services $0 co-pay 25 visits per 12 months $0 co-pay 25 visits per 12 months $0 co-pay 25 visits per 12 months DME $0 co-pay $0 co-pay $0 co-pay Substance Abuse $0 co-pay EPSDT only $0 co-pay EPSDT only $0 co-pay EPSDT only

* Physician Office Services includes physicians, certified pediatric and family nurse practitioners, nurse midwives, FQHCs, rural health clinics (RHCs), primary care centers (PCCs) and physician assistants. **Behavioral Health Services include mental health rehab/stabilization, behavioral support, psychological services and inpatient psychiatric services.