Please note: Copayments do not apply to
services provided at Indian Health Service facilities, services provided by
schools or to Native American Medicaid clients.
SCHIP Copayment Schedule
Service
|
Copayment
|
Comments
|
Outpatient Physician Visit
|
$5.00
|
|
Urgent Care Visit
|
$5.00
|
|
Outpatient Therapy Visit
|
$5.00
|
|
Other Practitioner Visit
|
$5.00
|
|
Dental Office Visit
|
$5.00
|
Does not apply if service
is preventive, diagnostic or orthodontic
|
Emergency Room Visit
|
$15.00
|
Does not apply if patient
is admitted to the hospital
|
Inpatient Hospital Admission
|
$25.00
|
|
Pharmacy Prescription
|
$2.00
|
Does not apply to medical
supplies
|
Missed Appointment
|
$5.00
|
If the patient does not
contact the provider to cancel the appointment according to the provider's
usual policy, the provider may charge the patient this copay.
|
Working Disabled Individuals (WDI) Copayment Schedule
Service
|
Copayment
|
Comments
|
Prescriptions
|
$5.00
|
Includes covered
prescription and non-prescription items.
|
Outpatient visit, other
practitioner visit, clinic visit, urgent care visit, outpatient therapy
sessions
|
$7.00
|
|
Dental Office Visit
|
$7.00
|
|
Emergency Room Visit
|
$20.00
|
|
Inpatient Hospital Admission
|
$30.00
|
|