Revision 18-4; Effective October 1, 2018

CHIP

Households are required to pay copayments for medical services or prescription drugs at the time of the service. The applicable copayment requirements are:

Coverage Description	At or below 151% FPIL	Above 151% up to and including 186% FPIL	Above 186% up to and including 201% FPIL
Preventative health care and shots	$0	$0	$0
Non-emergency ER visit	$5	$75	$75
Generic prescription	$0	$10	$10
Name-brand prescription	$5	$35	$35
Inpatient hospital care (per admission)	$35	$75	$125
Outpatient hospital care	$0	$0	$0
Other doctor visits	$5	$20	$25