Members are expected to pay copayments for prescriptions filled at the retail or mail order pharmacy. However, members may be exempt from paying a copayment for drugs for any of the reasons below:

• The member is under the age of 19.
• The member is pregnant (members must notify the doctor or pharmacist and contact the Plan).
• The member’s pregnancy ended in the last 60 days.
• The member is in hospice care.
• The member is receiving care as an inpatient in an acute hospital, nursing facility, chronic disease hospital, rehabilitation hospital, or intermediate-care facility for the mentally retarded.
• The member has met the annual copayment cap.
• MassHealth and Commonwealth Care plan type I members only: the member is receiving family planning supplies and/or family planning medication in a physician office.

Annual Copayment Cap
The Plan has placed an annual calendar copayment cap on out-of-pocket expenses based on the member’s plan type. MassHealth members are on calendar year from January to December. Commonwealth Care members are on a plan year from July to June.

You must first meet your annual out-of-pocket requirement before the annual out-of-pocket maximum applies. Once the annual out-of-pocket maximum is reached, you would no longer be required to contribute towards the cost of your prescriptions. See the table below for individual copayment caps:

Members will be notified by a letter if they have reached the copayment cap.

Copayment Reimbursement
If members believe that they have met the cap before receiving the letter from the Plan, they may submit the Proof of Copay Totals Form. Members will need to mail copies of their pharmacy receipts for drugs that they received since January 1 of that calendar year to the address below:

BMC HealthNet Plan
Attention: Pharmacy Copay
Two Copley Place
Suite 600
Boston, 02116-6597

If the member does not have receipts for all the copayments that they are charged, they may request a record of all prescriptions and copayments from their pharmacist.