Pharmacy Copayment Information for MassHealth Members

Prescription Copayments

The pharmacy copayment for each prescription filled or refilled is:

• $1 for generic antihyperglycemics, antihypertensives and antihyperlipdemics
• $3.65 for all other prescriptions and Over-the-Counter drugs

Copayment Cap

The total amount you can be charged for pharmacy copays within a year is $250.

The pharmacy copayment cap applies to each MassHealth Member of your family, age 19 and older, unless you are excluded (refer to list of copayment exceptions below). Once you meet the MassHealth copayment cap, NHP will send you a letter stating you do not have to pay copayments for the rest of the calendar year. You should keep the letter for your records and also a copy of all your copay receipts in case you need to refer to them. You can also request a prescription and copayment record printout from your pharmacist if you do not have receipts for all of the copays for which you were charged. You can call the NHP Member Service Center at 800-462-5449 or TTY 800-655-1761 to determine your copayment status and for more information about participating pharmacies.

Copayment Exceptions

The following MassHealth Members do not have to pay a pharmacy co-payment:

• Members under 19 years of age
• Members who are pregnant (You must tell the pharmacist you are pregnant.)
• Members whose pregnancy ended less than sixty (60) days ago.
• Members who are inpatients in acute hospitals, nursing facilities, chronic disease or rehabilitation hospitals, or intermediate-care facilities for the mentally retarded
• Members receiving hospice services
• Members receiving Family Planning supplies.
• Members who have met the pharmacy copay cap described above.

If one of the above exceptions applies to you, it is your responsibility to tell the pharmacist that you do not have to pay the co-payment. You will not be charged a pharmacy co-payment if any of the above exceptions apply to you.

What do you do if you cannot afford a copayment?

You must pay the co-payment if you can afford it; but if you can't, do not go without the medicine you need. Tell the pharmacist you can't afford to pay the co-payment. Under Federal Law, the pharmacy must still give you the medicine. You will still owe the money to the pharmacy and the pharmacy may use any legal way to collect the money you owe. NHP is not responsible for any co-payments you may owe to the pharmacy.