MedicaidReimbursementHigh impact
Updated Pharmacy Copayment Requirements for HealthChoice Maanged Care Organizations, Effective May 1, 2024
Maryland Medicaid·MD · Pharmacy·Provider Transmittal
Effective date
May 1, 2024
We identified it
Jun 20, 2026
Summary
Maryland HealthChoice MCOs must implement new pharmacy copayment tiers effective May 1, 2024: $3.00 for non-preferred brand drugs, $1.00 for generic drugs, preferred brand drugs, and HIV/AIDS drugs. Certain populations (under 21, pregnant individuals, long-term care residents, Native Americans) and specific drug categories (family planning, adult vaccines, COVID-19 treatments) are exempt from copayments. MCOs must educate providers and members 30 days before implementation.
Action Required
By April 1, 2024: Billing and pharmacy teams must (1) Update billing system to apply correct copayment tiers: $3.00 non-preferred brand, $1.00 generic/preferred brand/HIV-AIDS drugs; (2) Ensure system properly exempts patients under 21, pregnant individuals, long-term care residents, and Native Americans from all copayments; (3) Verify family planning drugs, adult vaccines, and COVID-19 drugs are flagged as copayment-exempt; (4) Communicate copayment changes to all clinical and front-desk staff. By May 1, 2024: Pharmacy and billing teams must ensure all HealthChoice claims correctly apply new copayment structure. Train staff that pharmacies cannot deny prescriptions due to unpaid copayments. Update internal documentation and patient education materials. Failure to implement correct copayment tiers will result in claim processing errors and member confusion.