Benefits and Services
What is a copayment?
A copayment is an amount that some insurance plans require you to pay as your share of the cost for a medical service like a doctor’s visit or a prescription. If premiums are paid timely, a member can avoid paying copayments. Our benefits that require a copayment are listed below. If you qualify for medically frail, you may be exempt from copayments.
Please note providers who have a posted policy that requires copayments be made before services rendered can deny service for members who are above 100% of the FPL if they have the inability to pay. For members below 100% FPL they are unable to be denied services.
|Service or Item||Copay|
|Preferred and non-preferred generic drug||$1|
|Brand name preferred on formulary over generic equivalent||$1|
|Brand name drugs||$4|
|Specialty visits (Chiropractor, Dental, Vision, Podiatry (foot))||$3|
|Therapy services (Physical therapy, Speech therapy, Occupational therapy)||$3|
|Officevisit (With a physician, physician’s assistant, advanced registered nurse practitioner, certified pediatric and family nurse practitioner, nurse midwife, or any behavioral health professional)||$3|
|Laboratory, diagnostic, or x-ray service||$3|
|Outpatient hospital service||$4|
|Durable medical equipment||$4|
|Outpatient surgery (ambulatory surgical center)||$4|
|Emergency room visit for a non-emergency service||$8|
|Inpatient services (Hospital admission or Mental health/Substance abuse admission)||$50|
You should not be billed for covered services. If you do get a bill, please call us. If you have more questions, call Member Services at 1-855-852-7005 (TTY: 1-800-648-6056 or 711).
Services Not Covered
Humana – CareSource will not pay for the following services that are not covered by Medicaid:
- All services or supplies that are not medically necessary
- Experimental services and procedures, including drugs and equipment, not covered by Medicaid
- Abortions except in the case of a reported rape, incest or when medically necessary to save the life of the mother
- Infertility services for males or females, including reversal of voluntary sterilizations
- Voluntary sterilization if under 21 years of age or if legally incapable of consenting to the procedure
- Plastic or cosmetic surgery that is not medically necessary
- Sexual or marriage counseling
- Inpatient treatment to stop using drugs and/or alcohol (In-patient detoxification services in a general hospital are covered.)
- Drugs not covered by the Kentucky Medicaid pharmacy program, including drugs for the treatment of obesity
- Services for the treatment of obesity unless determined medically necessary
- Inpatient hospital custodial care or comfort items in the hospital (e.g., TV or phone)
- Acupuncture and biofeedback services
- Services to find cause of death (autopsy) or services related to forensic studies
- Services determined by another third-party payer as not medically necessary
- Paternity testing
This is not a complete list of the services that are not covered. To learn more, review your member handbook (English or Spanish). Please call Member Services at 1-855-852-7005 (TTY: 1-800-648-6056 or 711) if you have a question about whether or not a service is covered.
Member Services: 1-855-852-7005 (TTY: 1-800-648-6056 or 711), 7 a.m. – 7 p.m., Monday – Friday