(1) Except as provided in (2) and (3), the parent or guardian of each CHIP enrollee whose family income is greater than 100% of the federal poverty level must pay to the provider of service the following copayments not to exceed the cost of service:

(a) $25 per admission for inpatient hospital services including hospitalization for physical, mental, and substance abuse reasons;

(b) $5 per visit for emergency room services;

(c) $5 per visit for outpatient hospital visits including outpatient treatment for physical, mental, and substance abuse reasons;

(d) $3 per visit for physician, APRN, PA, optometrist, audiologist, mental health professional, substance abuse counselor, or other covered health care provider services;

(e) $3 per prescription or refill of an outpatient generic drug;

(f) $5 per prescription or refill for an outpatient brand-name drug;

(g) $6 per mail order prescription or refill of an outpatient generic drug (90 day supply); and

(h) $10 per mail order prescription or refill of an outpatient brand name drug (90 day supply).

(2) No copayment shall apply to:

(a) well baby or well child care, including age-appropriate immunizations;

(b) outpatient hospital visits for x-ray and laboratory services;

(c) dental, pathology, radiology, or anesthesiology services;

(d) families with at least one enrollee who is a Native American Indian or Native Alaskan; or

(e) extended mental health services for children with a serious emotional disturbance as stated in ARM 37.79.316(4).

(3) The total copayment for each family shall not exceed $215 per family per benefit year.