(1) Except as provided in (2) and (3), the parent or guardian of each HMK coverage group 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; and

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

(2) No copayment will 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;

(e) extended mental health services for children with a serious emotional disturbance; or

(f) pharmacy services.

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