Out-of-Pocket Costs

Type of Service

All Kids Assist

All Kids Share

All Kids Premium Levels 1

evel 2

Doctor Visits

$0.00

$3.90

$5.00

$10.00

Rx Brand/ Generic Meds

$0.00

$3.90 – Brand

$2.00 – Generic

$5.00 – Brand

$3.00 – Generic

$7.00 – Brand

$3.00 – Generic

ER Visits

$0.00

$0 – ER Visit

$0 - Non-

Emergency

$5.00 – ER Visit

$25.00 – Non-

Emergency

$30.00 – ER Visit

$30.00 – Non-Emergency

Hospital Admission

$0.00

$3.90/Admission

$5.00/Admission

$100/Admission

Hospital Outpatient Services

$0

$3.90 Visit

$5.00 Visit

5% of HFS Rate

Max Co- Pays/Yr

No Max

$100 per family (all services)

$100 per family (all services)

$500 per child

No Co-pay for American Indians and Alaska Natives

Co-pays apply for American Indians and Alaska Natives

***NO CO-PAYS FOR WELL BABY CARE, WELL CHILD CARE, PREVENTATIVE DENTAL, IMMUNIZATIONS, OR FLU SHOT*** CO-PAYS MAY APPLY IF CLIENT IS SEEN FOR AN UNRELATED REASON.