16 Del. Admin. Code § 14000-14960
Section 1902(a)(14) of the Social Security Act permits states to require certain recipients to share some of the costs of Medicaid by imposing upon them such payments as enrollment fees, premiums, deductibles, coinsurance, co-payments, or similar cost sharing charges.
Effective January 10, 2005, clients have a nominal co-payment for generic and brand name prescription drugs as well as over-the-counter drugs prescribed by a practitioner.
The co-payment is based upon the cost of the drug as follows:
| Medicaid Payment for the Drug | Co-payment |
| $10.00 or less | $.50 |
| $10.01 to $25.00 | $1.00 |
| $25.01 to $50.00 | $2.00 |
| $50.01 or more | $3.00 |
The co-payment is imposed for each drug that is prescribed and dispensed.
9 DE Reg. 569 (10/01/05)
Effective July 1, 2005, there is a cumulative maximum monthly co-payment amount equal to $15.00 for each recipient. Any prescriptions dispensed after the cumulative maximum monthly co-payment amount is met are not subject to a co-payment.
9 DE Reg. 569 (10/01/05)
The following individuals and services are excluded from the co-payment requirement:
The pharmacy provider may not refuse to dispense the prescription(s) subject to the co-payment requirement because of the individual's inability to pay the co-payment amount. When a recipient indicates that he or she is unable to meet the co-payment requirement, the pharmacy provider must dispense the prescription(s) as written. Medicaid reimbursement for the prescription(s) will be the Medicaid fee minus the applicable co-payment amount.
The recipient remains liable for the co-payment amount and is responsible for paying the pharmacy when financially able. The pharmacy provider is permitted to pursue reimbursement of the co-payment amount from the recipient.
8 DE Reg. 1017 (1/1/05)
16 Del. Admin. Code § 14000-14960