​Copayment Information for Medical Assistance Recipients

Adult Medical Assistance beneficiaries: Medical Assistance beneficiaries will not be asked to pay a copayment for specific drugs generally used for the treatment of high blood pressure, cancer, diabetes, epilepsy, heart disease, HIV/AIDS, and psychosis. The Department of Human Services will determine which drugs do not require a copayment and will give that list of drugs to your pharmacy. You may see a copy of this list at your County Assistance Office or at your pharmacy. Additionally, Medical Assistance beneficiaries will not be required to pay a copayment for drugs and vaccines given to you directly by a physician.

The following is a list of copayments you will be asked to pay: 

• $3 for each day you are in a hospital, up to $21 for one hospital stay. This includes general hospitals, rehabilitation hospitals or private psychiatric hospitals.
• $1 for each prescription and prescription refill of a generic drug.
• $3 for each prescription and prescription refill of a brand name drug.
• $1 for each x-ray or other medical diagnostic tests or for treatment by nuclear medicine or radiation therapy.
• For outpatient psychotherapy services, the copayment is $.50 per unit of service.

For all other services, where copayments are required, the amount of the copayment is based on the Medical Assistance fee for the service, as shown in the following table:

Medical Assistance, Other Than General Assistance

General Assistance (GA) beneficiaries: The amount of the copayments you will be asked to pay is: 

• $6 for each day you are in a hospital, up to $42 for one hospital stay. This includes general hospitals, rehabilitation hospitals, and private psychiatric hospitals.
• $1 for each prescription and prescription refill of a generic drug
• $3 for each prescription and prescription refill of a brand name drug
• $2 for each x-ray or other medical diagnostic tests or for treatment by nuclear medicine or radiation therapy.
• For outpatient psychotherapy services, the copayment is $1.00 per unit of service.

For all other services where copayments are required, the amount of the copayment is based on the Medical Assistance fee for the service, as shown in the following table:

General Assistance

The copayment will never be more than the amount that the provider would bill to Medical Assistance. For example, if the Medical Assistance fee for a service is $52, and you have other medical insurance that pays the provider $50, your copayment would be the remaining $2 owed to the provider, not $3.

The doctor or other providers of service will tell you what the copayment amount is and will ask you to pay him or her. Each time you pay a copayment, you should ask for a receipt.

If you need a medical service and truly cannot pay the copayment amount at the time you receive the service, the provider will give you the service and bill you for the copayment. You will still owe the provider the copayment for that service and the provider will require you to pay the copayment.

If you think that the provider has made a mistake in charging you a copayment or has charged you too much, talk to the provider. If the provider disagrees with you, and you or your representative still believe that the provider is wrong, contact your County Assistance Office and explain why you think the provider made a mistake. Those complaints that the County Assistance office cannot resolve will be referred to the Office of Medical Assistance Programs in Harrisburg. The Office of Medical Assistance Programs will review your complaint and, if appropriate, take action against the provider which can include requiring the provider to repay to you the amount of the incorrect copayment charge. If you decide to continue to use that provider even though you disagree with the provider's copayment charge, unless and until the County Assistance Office or the Office of Medical Assistance Programs determines that the provider has made a mistake, you still have to make the copayment to that provider for that service.