Pharmacy Copayment Requirements for HealthChoice Managed Care Organizations

By April 30, 2024: Billing team must update pharmacy billing system to reflect new copayment tiers ($3.00 non-preferred brand, $1.00 generic/preferred brand/HIV-AIDS drugs). Configure system to automatically waive copayments for members under 21, pregnant women, hospice patients, Native Americans, and family planning drugs. Front desk staff must be trained not to deny pharmacy services when patients cannot pay copayments. Update patient education materials and provider communications to reflect new copay structure. Coordinate with MCO representatives to ensure member notifications are sent before effective date. Failure to implement copay changes may result in incorrect claim submissions and denials.