MedicaidCoverageMedium impact
Pharmacy Copay Requirements for HealthChoice Managed Care Organizations, Effective April 1, 2022
Maryland Medicaid·MD · Pharmacy·Provider Transmittal
Effective date
Apr 1, 2022
We identified it
Jun 20, 2026
Summary
Effective April 1, 2022, Maryland HealthChoice MCOs must implement standardized pharmacy copayments: $1.00 for preferred drugs and generic/HIV-AIDS drugs, and $3.00 for non-preferred drugs. However, copays do not apply to members under age 21, pregnant women, Native Americans, or family planning drugs. Pharmacy providers cannot deny services to members unable to pay copays.
Action Required
By April 1, 2022: Billing team must implement copay collection procedures in billing system for Maryland HealthChoice plans with the following tiered structure: $1.00 copay for preferred brand name, generic drugs, and HIV/AIDS drugs; $3.00 copay for non-preferred drugs. Front desk and billing staff must be trained to: (1) Verify member eligibility for copay exemptions (age under 21, pregnant status, Native American status); (2) Waive copays for all family planning drugs; (3) Never deny pharmacy services due to inability to pay copays per COMAR 10.09.03.03O. Update patient intake forms and billing software rules to capture exemption status. Ensure MCO education materials are distributed to providers and members. Contact Monchel Pridget at monchel.pridget@maryland.gov with questions. Failure to apply correct copays or denial of service due to nonpayment may result in compliance violations.