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Copays

The following chart shows a breakdown with the amounts you must pay, according to the services received and the type of coverage you have as a Government Health Plan enrollee.

Services

Federal CHIPS State Population ELA
100 110 230 300 310 320 330 400

HOSPITAL

Admission

$0

$3

$0

$3

$5

$6

$20

$50

Nursery

$0

$0

$0

$0

$0

$0

$0

$0

EMERGENCY ROOM

Emergency Room Visits

$0

$0

$0

$1

$5

$10

$15

$20

Non-emergency visit to a hospital emergency room

$3.80

$3.80

$0

$15

$15

$15

$15

$20

Trauma

$0

$0

$0

$0

$0

$0

$0

$0

AMBULATORY VISITS

Primary Care Physician

$0

$1

$0

$0

$1

$2

$2

$3

Specialist

$0

$1

$0

$1

$1

$3

$4

$7

Sub-specialist

$0

$1

$0

$1

$1

$3

$5

$10

Pre-Natal Services

$0

$0

$0

$0

$0

$0

$0

$0

OTHER SERVICES

High-Tech Laboratories

$0

50¢

$0

$1

$1

$2

$3

20%

Clinical Laboratories

$0

50¢

$0

$1

$1

$2

$3

20%

X rays

$0

50¢

$0

$1

$1

$2

$3

20%

Specialized Diagnostic Tests

$0

$1

$0

$1

$2

$2

$6

40%

Physical Therapy

$0

$1

$0

$1

$2

$2

$3

$5

Respiratory Therapy

$0

$1

$0

$1

$2

$2

$3

$5

Occupational Therapy

$0

$1

$0

$1

$2

$2

$3

$5

Vaccines

$0

$0

$0

$0

$0

$0

$0

$0

Healthy Child Care

$0

$0

$0

$0

$0

$0

$0

$0

DENTAL

Preventive (Children)

$0

$0

$0

$0

$0

$0

$0

$0

Preventive (Adults)

$0

$1

$0

$0

$1

$2

$3

$3

Restorative

$0

$1

$0

$0

$1

$5

$6

$10

PHARMACY

Generic (Children 0-18 age)

$0

$0

$0

$0

$0

$0

$0

$5

Generic (Adults)

$1

$1

 N/A

$1

$2

$3

$5

$5

Brand (Children 0-18 age)

$0

$0

$0

$0

$0

$0

$0

$10

Brand (Adults)

$3

$3

 N/A

$3

$4

$5

$7

$10

Services

Federal

CHIPS

Federal Population

ELA

100

110

230

300

310

320

330

400

 
 
*Code 400 in ELA column refers to the population that subscribes as public employees of the Puerto Rico Government.
**Apply to diagnostic tests only. Copays do not applied to tests required as part of a preventive service
***Copays apply to each drug included in the same prescription pad.  Pharmacy exception (children 0- 18) does not apply to 400 ELA employees.                                                   
****Co-pays for children 0-18 years of age are not applicable for Medicaid, Commonwealth medically indigent eligible, and for children 0-18 enrolled in the CHIP Program in group ages 0-18.
Co-pays may apply to children ages over 18 years old as well as to adults.
 

Enrollee Services
1-844-336-3331 (toll free)
787-999-4411 TTY (hearing impaired)
Monday through Friday
from 7:00 a.m. to 7:00 p.m.

Postal Address
PO BOX 72010
San Juan, PR 00936-7710

Physical Address
Fundación Ángel Ramos 
Ave. Chardón  
Hato Rey, PR

Policies

Non Discrimination