He-W 530.04 - Co-Payments

He-W 530.04. Co-Payments

(a) Recipients subject to co-payments shall make co-payments to the pharmacy provider for pharmaceutical products as follows, except as noted in (3) below:

(1) For recipients eligible for medicaid through the New Hampshire Health Protection Program (NHHPP) co-payments as required in He-W 512.

(2) For all other recipients subject to co-payments as required by this part:

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;

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 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; and

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

(3) Co-payments for pharmaceutical products shall not be required:

a. Of recipients exempt from co-payments in accordance with He-W 530.02(b);

b. For family planning products; and

c. For Clozaril (Clozapine) prescriptions.

(b) Recipients subject to co-payments shall make co-payments to the provider for services as follows, except as noted in (2) below:

(1) For recipients eligible for medicaid through the NHHPP, co-payments as described in He-W 512; and

(2) Recipients shall not be responsible for a co-payment for the following services:

a. Emergency services needed to evaluate or stabilize an emergency medical condition as defined in 42 CFR 438.114(a);

b. Provider-preventable services as described in 42 CFR ยง 447.26(b);

c. Services furnished to pregnant women, including counseling and pharmacotherapy for cessation of tobacco use;

d. Family planning services and supplies; and

e. Preventive services.

(c) Pursuant to 42 CFR 447.56(f), co-payment obligations shall be suspended for the remainder of the calendar year quarter when the total co-payments made out of pocket by the recipient reaches 5 percent of the recipient's household income.

(d) All recipients subject to co-payments required by this part shall not be denied services by any medicaid enrolled provider on account of the recipient's inability to pay the co-payments required by this part.

(Amended byVolume XXXIV Number 50, Filed December 11, 2014, Proposed by #10716, Effective 11/18/2014, Expires 11/18/2024. Amended by Volume XXXVI Number 23, Filed June 9, 2016, Proposed by #11101, Effective 5/25/2016, Expires 5/25/2026.)

(See Revision Note at chapter heading He-W 500); ss by #4863, eff 7-12-90, EXPIRED: 7-12-96

New. #6925, eff 1-1-99; ss by #7976, eff 10-22-03; ss by #8780, INTERIM, eff 1-1-07, EXPIRES: 6-30-07; ss by #8929, eff 6-30-07; amd by #10017, eff 11-1-11

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