Co-Pays

Services	Standard & SSI Plan	Co-Pay
*Pharmacy	State drug list	$.50 - $3 *
Medication given during a healthcare provider visit	Full coverage	MHS covers
Physician visits	Full coverage	MHS covers
Inpatient hospital	Full coverage	MHS covers
Outpatient hospital	Full coverage	MHS covers
Emergency room	Full coverage	MHS covers
Nursing home	Full coverage	MHS covers
Physical therapy	Full coverage	MHS covers
Home health	Full coverage	MHS covers
Medical equipment	Full coverage	MHS covers
Medical supplies	Full coverage	MHS covers
*Transportation	Routine to & from covered services	Full coverage
Ambulance	Full coverage	MHS covers
*Dental	Preventive, restorative, palliative	*$1 - $3
Vision	One exam & glasses per year	MHS covers
Added vision	$100 allowance for better frames or $80 toward contact lenses	MHS covers
Hearing	Full coverage	MHS covers
Hospice	Full coverage	No co-pay
Family planning	Full coverage	No co-pay
*Chiropractor	Full coverage	*$3
Podiatrist	Full coverage	MHS covers
Mental health outpatient	Full coverage	MHS covers
Mental health inpatient	Full coverage for age 0-21. (Stays for ages 22-64 in institutional settings are not covered).	MHS covers
Residential treatment	Short-term coverage for substance abuse	*No co-pay
Health education	MHS added benefit	Asthma, diabetes, hypertension

*Depending on your county of residence the dental benefit may be provided by MHS or by the state. Pharmacy and chiropractic services are provided by the state in all areas. You may access this care from any provider that will accept your ForwardHealth card. Routine transport is provided by the state through a separate company.

Services Not Covered

Medically unnecessary services
Reversal of voluntary sterilization
Infertility treatments
Surrogate parenting and related services
Artificial insemination
Inpatient mental health stays in institutional settings for ages 22 – 64
Experimental procedures and treatments