405 Ind. Admin. Code 5-24-7

Current through October 31, 2024

Section 405 IAC 5-24-7 - Copayment for legend and nonlegend drugs

Authority: IC 12-15-1-10; IC 12-15-21-2

Affected: IC 12-13-7-3; IC 12-15-6

Sec. 7.

(a) Under IC 12-15-6, a copayment is required for legend and nonlegend drugs in accordance with the following:

(1) The copayment shall be paid by the member and collected by the provider at the time the service is rendered. Medicaid reimbursement to the provider shall be adjusted to reflect the copayment amount for which the member is liable.

(2) In accordance with 42 CFR 447.15, the provider may not deny services to any eligible individual on account of the individual's inability to pay the copayment amount. Under 42 CFR 447.15, this service guarantee does not apply to an individual who is able to pay, nor does an individual's inability to pay eliminate his or her liability for the copayment.

(3) The amount of the copayment will be three dollars ($3) for each covered drug dispensed. The pharmacy provider shall collect a copayment for each drug dispensed by the provider and covered by Medicaid.

(b) The following pharmacy services are exempt from the copayment requirement:

(1) Emergency services provided in a hospital, clinic, office, or other facility equipped to furnish emergency care.

(2) Services furnished to individuals less than eighteen (18) years of age.

(3) Services furnished to pregnant women if such services are related to the pregnancy or any other medical condition that may complicate the pregnancy.

(4) Services furnished to individuals who are inpatients in hospitals, nursing facilities, intermediate care facilities for individuals with intellectual disabilities, or other medical institutions.

(5) Family planning services and supplies furnished to individuals of child bearing age.

405 IAC 5-24-7

Office of the Secretary of Family and Social Services; 405 IAC 5-24-7; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3346; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Nov 4, 2002, 12:16 p.m.: 26 IR 732; filed Feb 24, 2004, 10:45 a.m.: 27 IR 2252; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR- 405130241RFA

Filed 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRA

Filed 4/29/2019, 10:35 p.m.: 20190529-IR-405180482FRA

Readopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA