Pharmacy Copays

Pharmacy Medicaid copayment requirements

An eligible Medicaid member, who receives prescribed drugs, is required to make a co-payment of $4 for each prescription received unless they are exempt. A provider may not deny services to any Medicaid member because of the individual's inability to pay a deductible, coinsurance or co-payment amount.

A Medicaid member is exempt from a copayment for any one of the following:

  1. The member is under 21 years of age.
  2. The member resides in a nursing home facility, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) or a mental health hospital. Adult care home and hospice beneficiaries are responsible for copayment.
  3. The drug is classified as family planning (birth control medication).
  4. The member is classified as a CAP member as indicated on the member's Medicaid Identification Card (MID card)
  5. The member is pregnant. The pharmacy may use any of the ICD-10-CM codes to indicate pregnancy. A "4" in the Prior Authorization Type Code or a "2" in the pregnancy indicator field on a point-of-sale (POS) claim also indicates an exemption from the copayment deduction for pregnancy.
  6. The member belongs to a federally recognized tribe.
  7. The member is enrolled in NC Breast and Cervical Cancer Control Program (NCBCCCP).

NC Health Choice copayment requirements

NC Health Choice members are required to make co-payments according to the income levels listed below:

Income level Co-payment
Class A
Less than or equal to 150% of Family Poverty Level and Native American or Alaska Native		 • No copayment
Class J
Less than or equal to 150% of Family Poverty Level

• Generic: $1
• Brand with no generic: $1
• Brand with generic: $3
• Over the counter (OTC) medication: $1
Class K
151% – 200% of Family Poverty Level		 • Generic: $1
• Brand with no generic: $1
• Brand with generic: $10
• OTC medication: $1
Class S
151% – 200% of Family Poverty Level and Native American or Alaska Native		 • No copayment
Class L (optional extended coverage)
201% – 225% of Family Poverty Level		 • Generic: $1
• Brand with no generic: $1
• Brand with generic: $10
• OTC medication: $1
Providers