1. (1) Medicaid recipients are required to pay the designated Copay amount for each prescription filled and each refill.
2. (2) The cost-sharing fee does not apply to family planning drugs and supplies, or to drugs prescribed for recipients under 18 years of age, recipients who are in a nursing facility or services furnished to pregnant women.
3. (3) When a pharmacy fills a prescription for a Medicaid recipient under eighteen (18) years of age, the pharmacist must verify the age of the individual by checking the date of birth on the eligibility card. Copayment on drug claims for family planning drugs and supplies will be determined by the national drug code numbers. No further indication is necessary on the claim form for a Medicaid recipient under eighteen (18) years of age or for claims submitted for family planning drugs and supplies.
4. (4) When a pharmacy fills a prescription for a Medicaid recipient residing in a nursing facility in Alabama the pharmacy provider must indicate a large "I" in the Copay block on the Medicaid Pharmacy Claim Form or appropriate space for other approved drug claim submission methods (i.e., continuous feed form, tape-to-tape, etc.).
5. (5) When a pharmacist dispenses a prescription for a Medicaid eligible woman on which the physician has written PREGNANT, the pharmacist shall place a "p" in the Copay block on the Medicaid Pharmacy Claim Form or appropriate space for other approved drug claim submission methods (i.e., continuous feed form, tape-to-tape, etc.).
6. (6) Copayment Collection: Copayment is based on drug ingredient cost of the dispensed prescription. The schedule is furnished by the Medicaid Agency Pharmacy Program.
7. (7) A provider may not deny services to any eligible individual on account of the individual's inability to pay Copayment amount.

Author: Sam T. Hardin; Larry A. Tatum

Statutory Authority: State Plan, Attachments 3.1A, 4.18B; Title XIX, Social Security Act; 42 C.F.R. §§ 447.15, 447.53, 447.331; Omnibus Budget Reconciliation Act of 1990 (Public Law 101-508.).

History: Rule effective October 1, 1982. Amended: Effective September 8, 1983; December 6, 1984; June 8, 1985; April 14, 1992. Amended: Filed January 6, 1998; effective February 10, 1998.