Members of NJ FamilyCare C and D Must Pay the Following Fees:

NJ FamilyCare C. 1. Co-pays between $1 and $10. Eskimos and Native Americans under age 19 do not have a co-pay. 2. Total annual co-pays will not be more than 5% of your family’s yearly income. It’s your responsibility to keep track of your total co-pays for the year. Call the Health Benefits Coordinator at 1-800-701-0710 (TTY: 1-800-701-0720) once you reach your yearly limit. If you have questions about these NJ FamilyCare rules, please call Member Services toll-free at 1-800-941-4647, TTY: 711.

(Subject to change) NJ FamilyCare C (Personal contributions to care). Note: Co-payments are required only if indicated on your ID card. Outpatient hospital visits (except for preventive services) ...... $5 Emergency services in a hospital: Emergency Room...... $10 Physician visits (except for well-child visits, lead screening and treatment, age-appropriate immunizations, prenatal care, and pap smears, when appropriate)...... $5 Independent clinic visits (including Federally Qualified Health Centers; except for preventive services) ...... $5 Podiatrist visits (foot doctor) (no routine care)...... $5 Optometrist visits...... $5 Nurse midwife visits (except for prenatal care visits) ...... $5 Dentist visits (except for diagnostic and preventive services)...... $5 Chiropractor visits...... $5 Nurse practitioner visits (except for preventive care services) ...... $5 Generic prescription drugs...... $1 Brand name prescription drugs...... $5

NJ FamilyCare D. 1. NJ FamilyCare D members pay a monthly premium depending on family income and household size. Call NJ FamilyCare at 1-800-701-0710 (TTY: 1-800-701-0720) for more information. 2. Co-payments, not to exceed $35 per service. Eskimos and Native Americans do not have a co-pay. 3. Total annual premiums and co-pays will not be more than 5% of your family’s yearly income. It’s your responsibility to keep track of your total payments for the year. Call the Health Benefits Coordinator at 1-800-701-0710 (TTY: 1-800-701-0720) once you reach your yearly limit. If you have questions about these NJ FamilyCare rules, please call Member Services toll-free at 1-800-941-4647, TTY: 711.

CSNJ16MC3856226_000 (Subject to change) NJ FamilyCare D co-payments. Note: Co-payments are required only if indicated on your ID card. Primary care/specialist physician office visits during normal office hours (except for well-child care, lead screening and treatment, age-appropriate immunizations, prenatal care)...... $5 Primary care/specialist physician office visits during non-office hours or home visit ...... $10 Dentist visits (except for diagnostic and preventive care services)...... $5 Initial maternity visit (to doctor or nurse midwife) during normal office hours...... $5 Initial maternity visit (to doctor or nurse midwife) during non-office hours ...... $10 Nurse practitioners visit (except preventive services)...... $5 Nurse practitioners visit during non-office hours (except for preventive services)...... $10 Optometrist visits (except for newborns covered under fee-for-service)...... $5 Podiatrist visits (foot doctor) (no routine care)...... $5 Psychologist services...... $5 Laboratory and X-ray services that are not part of an office visit...... $5 Emergency room services (except if admitted to the hospital or if referred to the emergency room by your PCP for services that should have been given in the doctor’s office)...... $35 Outpatient hospital clinic visits (except for preventive services)...... $5 Prescription drugs...... $5 Prescription drugs — more than a 34-day supply ...... $10 Hospital outpatient mental health services...... $5 Outpatient substance abuse services for detoxification ...... $5 Outpatient rehabilitation visits...... $5

There are no co-payments for the following services: • Emergency ambulance services. • All maternity visits after the first visit. • Outpatient surgery. • Home health services. • Hospice services. • Inpatient hospital services. • Inpatient substance abuse detoxification services. • Inpatient mental health services. • Diagnostic and preventive dental services.