Ala. Admin. Code r. 560-X-16-.10 - Cost-Sharing

Current through Register Vol. 39, No. 12, September 30, 2021

(1) Medicaid recipients are required to pay the designated CO-pay amount for each prescription filled and each refill.
(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) 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. CO-payment 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) 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 CO-pay 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) 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 CO-pay 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) Copayment Collection: Copayment is based on drug ingredient cost of the dispensed prescription. The schedule is furnished by the Medicaid Agency Pharmacy Program.
(7) A provider may not deny services to any eligible individual on account of the individual's inability to pay CO-payment amount.

Authors: Sam T. Hardin; Larry A. Tatum

Notes

Ala. Admin. Code r. 560-X-16-.10
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.

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.).

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