Co-Pays
MEDICAID CO-PAYS
Below is information about co-payments for Georgia Medicaid members only.
You may have to make a small co-payment when you get care. This depends on your Medicaid group. But Peach State Health Plan will pay for most, if not all of your bill. Doctors, hospitals or other providers in the Medicaid program must accept Medicaid as payment. But they may bill you for your co-payment.
Those who do not have co-payments are:
- Medicaid member under age 21
- PeachCare for Kids® members under age 6
- Pregnant women
- Members with breast and /or cervical cancer
- Nursing home members
- Members in hospice care
- American Indians
- Alaska Natives
If you cannot pay your copay, you will not be denied care for a covered service.
Co-Payments
| COST OF PRESCRIBED DRUG IS | MEMBER PAYS |
|---|---|
| Less than $ 10.01 | $0.50 cents |
| Between $ 10.01 – $ 25.00 | $1.00 |
| Between $ 25.00 – $ 50.00 | $2.00 |
| More than $ 50.01 | $3.00 |
Note: Co-payments are not required for the following:
- Family planning services
- Services for children under the age of 21
- Pregnant women
- Nursing home residents
- Hospice care members
- Emergency services
- Prescriptions for family planning services
- Emergency Room generated prescriptions
- Members with breast or cervical cancer
Please call our Member Services Department:
- For more information about the Preferred Drug List
- To find out how to get an administrative review on a PA decision
- To ask if your drug is covered
- To learn more about health education services at no cost to you
Services
Co-payments are required for the following:
| TYPE OF SERVICE | CO-PAYMENT AMOUNT |
|---|---|
| Ambulatory Surgical Centers | $3.00 |
| Federally Qualified Health Centers & Rural Health Centers | $2.00 |
| Outpatient | $3.00 (non-emergency visits) |
| Inpatient | $12.50 |
| Emergency Department Visits for Non-Emergency Medical Conditions | $3.00 |
| Oral Maxillofacial $10.00 or Less | $.50 |
| Oral Maxillofacial $10.01 to $25.00 | $1.00 |
| Oral Maxillofacial $25.01 to $50.00 | $2.00 |
| Oral Maxillofacial $50.01 or More | $3.00 |
PEACHCARE FOR KIDS® CO-PAYS
We want to let you know of updates to the PeachCare for Kids® copay amount you pay for services.
Some members do not have to pay copayments, including:
- Pregnant women
- Hospice care members
- Nursing facility residents
- Medicaid members younger than age 21
- PeachCare for Kids® members age six and under
The charts below show copay amounts listed by services and replace the charts in the Copayments section of your member handbook. Please refer to the chart below for copay amounts.
| TYPE OF SERVICE | CO-PAYMENT AMOUNT |
|---|---|
| Ambulatory Surgical Centers/Birthing Centers | $3.00 |
| Durable Medical Equipment | $1.00 or $3.00 (service based) |
| Federally Qualified Health Centers | $2.00 |
| Free Standing Rural Health Clinic | $2.00 |
| Home Health Services | $3.00 |
| Hospital-based Rural Health Center | $2.00 |
| Inpatient Hospital services | $12.50 |
| Oral Maxillofacial Surgery | Co-pay amount based on cost of service *see chart below |
| Orthotics and Prosthetics | $3.00 |
| Outpatient Hospital Services | $3.00 |
| Pharmacy - Preferred Drugs | $.50 |
| Pharmacy - Non-Preferred Drugs | Co-pay amount based on cost of service *see chart below |
| Physician Services | Co-pay amount based on cost of service *see chart below |
| Podiatry | Co-pay amount based on cost of service *see chart below |
| Vision Care | Co-pay amount based on cost of service *see chart below |
*The co-payment amounts below are for the following services: Oral Maxillofacial Surgery, Pharmacy – Non-Preferred Drugs, Physician Assistant Services, Physician Services (Doctor’s office visits), Podiatry and Vision Care.
| COST OF SERVICE | CO-PAYMENT AMOUNT |
|---|---|
| $10.00 or less | $0.50 |
| $10.01 to $25.00 | $1.00 |
| $25.01 to $50.00 | $2.00 |
| $50.01 or more | $3.00 |
If you have any questions about these changes, please contact Peach State Health Plan's Member Services Department toll free at 1-800-704-1484. You can call Monday through Friday from 7:00 a.m. to 7:00 p.m. Eastern Time. If you are hearing impaired, please call TTY/TDD 1-800-255-0056.