Recipients shall make co-payments to the pharmacy provider for drug products as follows:

1. (a) A co-payment in the amount of $1.00 shall be required for each preferred prescription drug and each refill of a preferred prescription drug dispensed;
2. (b) A co-payment in the amount of $2.00 shall be required for each non-preferred prescription drug and each refill of a non-preferred prescription drug dispensed unless the prescribing provider determines that a preferred prescription drug will be less effective for the recipient, will have adverse effects for the recipient, or both, in which case the co-payment shall be $1.00;
3. (c) A co-payment in the amount of $1.00 shall be required for a prescription drug that is not identified as either a preferred or non-preferred prescription drug; and

4. (d) Co-payments for drug products shall not be required:

   1. (1) Of recipients with income at or below 100% of the federal poverty level (FPL);
   2. (2) Of recipients in a nursing facility, hospital, intermediate care facility for individuals with intellectual disabilities, or other medical institution;
   3. (3) Of recipients participating in the home and community based care (HCBC) waiver programs;
   4. (4) Of recipients receiving services that relate to pregnancy in accordance with 42 CFR 447.53 (b)(2), or any other medical condition that might complicate the pregnancy;
   5. (5) Of recipients under the age of 18;
   6. (6) For family planning products;
   7. (7) For clozaril or clozapine prescriptions;
   8. (8) Of women eligible through the Breast and Cervical Cancer Treatment Program, pursuant to 42 CFR 435.213;
   9. (9) Of recipients receiving hospice care pursuant to He-W 544; and
   10. (10) Of individuals who are members of a federally recognized Indian tribe or Alaskan natives who have ever been served through the Indian Health Services Program, pursuant to 42 CFR 447.56(a)(x).

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93, EXPIRED: 12-1-99 New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02 New. #7805, eff 12-21-02; ss by #7976, eff 10-22-03; ss by #9831, eff 12-21-10; ss by #10716, eff 11-18-14; ss by #11101, eff 5-25-16; ss by #12529, eff 5-22-18; ss by #12698, eff 12-28-18