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Service/Item Co-payment Limitations/Cumulative Maximum Comprehensive Community Services (CCS) No co-payment n/a Crisis Intervention No co-payment n/a Dental Services $0.50 to $3 per service Co-payment obligation depends on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service:

Fee

Co-payment $10 or less…………………….$0.50 $10.01 to $25………………....$1.00 $25.01 to $50………………....$2.00 $50.01 or more…………….….$3.00

Disposable Medical Supplies $0.50 per item n/a Drugs Over-the-counter (OTC): $0.50 Generic:

$1.00 Brand name:

$3.00  Co-payment obligation limited to $12 per month, per member, per provider

 OTCs are excluded from this $12 per month maximum

WISCONSIN

Effective Date:

Approval Date: 46