The WVCHIP Plan has two levels
of copayment participation*. Members
under Group A have copayments
for brand name prescription drugs
only. Members under Group B have
copayments for prescription drugs
and for some medical and other
health services.
Group A
Members in this group receive
insurance cards marked “Drug
CoPays Only.” Copayments
are required for prescription
drugs according to the following
schedule:
Drugs
(1-34 Day Supply) |
| Amount |
Type |
| $0 |
Generic |
| $5 |
Listed Brand Drugs |
| Full Retail Cost |
Non-Listed Drugs |
Group B
Members in this group receive
insurance cards marked “CoPays
Apply.” Copayments apply
to prescription drugs and some
medical services under the following
schedules:
DRUGS |
MEDICAL
SERVICES |
| Copayment |
Type |
Copayment |
Type |
| $0 |
Generic |
$15 |
Physician Visit for Illness |
| $10 |
Listed Brand Drugs |
$25 |
Hospital/Inpatient Services |
| Full Retail Cost |
Non-Listed Drugs |
$25 |
Outpatient Services(per
procedure) |
| |
$35 |
Emergency Room(waived if
admitted) |
No
copayments apply for preventive
services such as well-baby
and well-child check-ups,
immunizations,
and dental
and vision preventive check-ups.
|
Premium Plan
Healthcare coverage under the premium plan has a monthly premium payment (One child = $35 a month and Two or more children = $71 a month). Coverage will begin the first day of the following month after payment is received.
Members in this plan will receive a card marked Premium Plan, Copays Apply, Preventive Dental Services only and no vision coverage. Copayments apply to prescription drugs and some medical services under the follwoing schedules:
Medical Services
and
Prescription Benefits
|
|
| Generic Prescriptions |
No Copay |
| Listed Brand Prescriptions |
$15 |
| Non-listed Brand Prescriptions |
Full Retail Cost |
| Physician Visit for Illness |
$20
|
| Hospital/Inpatient Service |
$25 |
| Outpatient Services (per procedure) |
$25 |
| Emergency Room (is waived if admitted) |
$35 |
| Dental Services |
$150 Annual Limit |
| Vision Services |
100% Out of Pocket |
| Immunizations |
No Copay |
| Well-child Visits |
No Copay |
Copayment Maximums for Regular CHIP Plan (Group A/B)
The maximum copayment amounts
that may be required during a
benefit year are as follows:
Prescription Drug
Maximums |
Medical Services
Maximums |
Total Maximum Copayments Per Benefit Year |
| $100 maximum per 1 child |
$150 maximum per 1 child |
$250 |
| $200 maximum per 2 children |
$300 maximum per 2 children |
$500 |
| $300 maximum for 3 or more
children |
$450 maximum for 3 or more
children |
$750 |
Copayment Maximums for WV CHIP Premium Plan
The maximum copayment amounts that may be required during a benefit year are as follows:
Prescription
Drug Maximums
|
Medical Services
Maximums
|
Total Maximum Copayments |
| $150 Maximum per 1 child |
$200 Maximum per 1 child |
$350.00 |
| $250 Maximum per 2 children |
$400 Maximum per 2 children |
$650.00 |
| $350 Maximum 3 or more children |
$600 Maximum per 3 or more |
$950.00 |
*Federal regulation permits the
exemption of Native American/Alaskans
from copayments. Click here for a list of federally recognized tribes.
Click here for the WVCHIP Drug
Formulary.
|
