Pharmacy Copays

Pharmacy Medicaid copayment requirements

An eligible Medicaid member, who receives prescribed drugs, is required to make a co-payment of $4 for each prescription received unless they are exempt. A provider may not deny services to any Medicaid member because of the individual's inability to pay a deductible, coinsurance or co-payment amount.

A Medicaid member is exempt from a copayment for any one of the following:

1. The member is under 21 years of age.
2. The member resides in a nursing home facility, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) or a mental health hospital. Adult care home and hospice beneficiaries are responsible for copayment.
3. The drug is classified as family planning (birth control medication).
4. The member is classified as a CAP member as indicated on the member's Medicaid Identification Card (MID card)
5. The member is pregnant. The pharmacy may use any of the ICD-10-CM codes to indicate pregnancy. A "4" in the Prior Authorization Type Code or a "2" in the pregnancy indicator field on a point-of-sale (POS) claim also indicates an exemption from the copayment deduction for pregnancy.
6. The member belongs to a federally recognized tribe.
7. The member is enrolled in NC Breast and Cervical Cancer Control Program (NCBCCCP).