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Service/Item Co-payment Limitations/Cumulative Maximum • Co-payment obligation limited to the first 30 hours or $1,500, whichever occurs first, during one calendar year.

Physician Services (including Nurse Midwife, Nurse Practitioner, Laboratory and Radiology services)

$0.50 to $3 per service, except allergy testing co-payment is applied per date of service  Co-payment based on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service provided:

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

 The co-payment obligation for physician services is limited to $30 per member, per provider, per calendar year.

 There is no co-payment for anesthesia services.

Podiatry Services $.50 to $3 per visit  Co-payment based on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service provided:

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

WISCONSIN

Effective Date:

Approval Date: 50