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UPDATED: JANUARY 2012

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OTHER ELIGIBILITY REQUIREMENTS

CO-PAY

SERVICE FFS MC FHP FPBP Inpatient Hospital YES NO YES NO Outpatient Hospital & Clinic YES NO YES NO Non-emergency/Non-urgent ER YES NO YES NO Prescription drugs * (brand name) (generic) YES YES YES NO Over-the-Counter Drugs** YES YES YES NO Enteral/Parenteral Formulae/Supplies YES NO YES N/A Covered Medical/Surgical Supplies *** YES NO YES NO Laboratory YES NO YES NO X-ray **** YES NO YES NO Dental services NO NO YES N/A Physician services NO NO NO NO Family Planning services and supplies NO NO NO NO

* One co-payment charge for each new prescription and each refill

** Covered OTC e.g. smoking cessation products, insulin

*** Covered medical supplies e.g. diabetic supplies such as syringes, lancets, test strips, enteral formula

**** Radiology services e.g. diagnostic x-rays, ultrasound, nuclear medicine & oncology services

Recipients exempt from co-payment include the following:

Recipients under the age of twenty-one (21)

Pregnant women (This exemption continues for 2 months after the month in which the pregnancy ends.)

Recipients institutionalized in a medical facility who are required to spend all of their income, except for a personal needs allowance, on medical care. This includes all recipients in nursing facilities and Intermediate Care Facilities for the Developmentally Disabled (ICF/DD).

Recipients enrolled in Medicaid Managed Care Plans (with the exception of pharmacy co-payments and OTC).

Recipients enrolled in FPBP only cases or who receive FPBP only coverage (Coverage Code 18) in an MA case.

(MRG)