Drug Costs

The drug formulary is more than just a list of medications. It can also help you figure out what your cost (or copay) for a medication will be and whether there is a lower cost option. 

 

When searching for a drug, pay attention to the drug tier listed next to it. Then find your plan type below to see the cost for that drug tier. If no tier is listed, there may be a restriction on that particular drug, and you may need to try another medication first. In some cases, your doctor needs to ask us for approval to prescribe you a medication before we can cover it.

MassHealth Drug Costs

 

 

Supply Type

Tier 1 

For generic high blood pressure, high 
cholesterol & diabetes

Tier 1

For all other generic
and over-the-counter Drugs

Tier 2

Covered Brand Drugs

Retail

(1-Month Supply)

$1.00 $3.65  $3.65

Mail Order

(3-Month Supply)

$1.00 $3.65  $3.65

Members (19 years of age and older) may need to pay a portion of the cost of covered drugs that may be obtained at the retail and mail order pharmacies until the member has met their annual copayment cap. This out-of-pocket copayment is collected at the pharmacy at the time the prescriptions are filled. To find out what copayment tier your medication is in use our Drug Finder

MassHealth members may be exempt from paying a copayment for drugs for any of the following reasons:

  • The member is under the age of 19.
  • The member is pregnant (members must notify their doctor to submit a Medical Prior Authorization Form).
  • The member’s pregnancy ended in the last 60 days (members must notify their doctor to submit a Medical Prior Authorization Form).
  • The member is in hospice care.
  • The member is a Native American or Alaska Native from a federally recognized tribe. 
  • 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 developmentally delayed.

Annual Copayment Cap

Each member has a maximum amount that they can spend on copayments each year called an annual copayment cap. Once the cap is reached you will no longer have to pay copays on your prescriptions. MassHealth members are on calendar year from January to December. 

Plan Type


Annual Copayment Cap


MassHealth

$250

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

You can register/log in to envisionrx.com to find the cost of a specific drug

Note: Pharmacies may not refuse service to a MassHealth member who cannot pay the copayment. However, the pharmacy may bill the member later for the copayment.

Retail Prescriptions (1-Month Supply)

Plan Name

 Tier 1

   Generic Drugs

Tier 2

 Preferred Brand
Drugs

Tier 3

Non-Preferred
Brand and
Specialty Drugs

ConnectorCare I
Individual out-of-pocket maximum: $250
Family out-of-pocket maximum: $500
$1 $3.65 $3.65
ConnectorCare II
Individual out-of-pocket maximum: $500
Family out-of-pocket maximum: $1,000
$10 $20 $40
ConnectoreCare III
Individual out-of-pocket maximum: $750
Family out-of-pocket maximum: $1,500
$12.50 $25 $50
ConnectorCare Zero
& Limited Cost Share Select

Individual out-of-pocket maximum: None
Family out-of-pocket maximum: None
 $0 $0 $0 
ConnectorCare Zero
& Limited Cost Share Silver

Individual out-of-pocket maximum: None
Family out-of-pocket maximum: None
 $0 $0  $0 
Mail-Order Prescriptions (3-Month Supply)
Plan Name

Tier 1

   Generic Drugs

Tier 2

Preferred Brand
Drugs

Tier 3

Non-Preferred
Brand and
Specialty Drugs

ConnectorCare I $2 $7.30 $7.30
ConnectorCare II $20 $40  $80
ConnectoreCare III $25 $50 $100
ConnectorCare Zero 
& Limited Cost Share Select
$0  $0 $0 
ConnectorCare Zero
& Limited Cost Share Silver
$0  $0  $0 

You can also view your prescription costs in the Prescription Drug section of Schedule of Benefits. You can find the tier of a prescription drug by searching our Drug Finder.

ConnectorCare and Qualified Health Plan members may be exempt from paying a copayment for the following reasons:

  • The member is receiving family planning supplies and/or family planning services
  • The member has met the annual out-of-pocket maximum when applicable

Each member has an out-of-pocket maximum based on the member's plan type. Once the annual out-of-pocket maximum is reached, you will no longer be required to contribute towards the cost of your prescriptions. You can find your yearly out-of-pocket maximum in your Schedule of Benefits.

You can register/log in to envisionrx.com to find the cost of a specific drug.

The costs in the table below show your drug costs after you reach your annual deductible. Your deductible is the amount you have to pay for services before we start to pay. Until you reach your annual deductible, you will be responsible for the full cost of the drug. To find your annual deductible amount, click on your plan type below to see your Schedule of Benefits

Each member also has an out-of-pocket maximum. This is the most you can pay for covered services during a coverage period (usually one year). Oce the maximum is reached, you no longer need to pay for your prescriptions. You can find your yearly out-of-pocket maximum in your Schedule of Benefits.

Retail Prescriptions (1-Month Supply)

   Plan Name    

Tier 1

Generic Drugs

Tier 2

Preferred Brand
Drugs 

Tier 3

Non-Preferred Brand
and Specialty Drugs 

Platinum
$10 $25 $50
Gold
$20 $40 $60
Low Gold
$25 $50 after deductible $125 after deductible
Silver A
$30 $60  $100 after deductible 
Silver A II
$30 $60  $100 after deductible 
Silver B
$30 after deductible 35% after deductible  35% after deductible 
Bronze $30 $60 after deductible  $125 after deductible 
Mail-Order Prescriptions (3-Month Supply)
   Plan Name     

Tier 1

Generic Drugs

Tier 2

Preferred Brand
Drugs

Tier 3

Non-Preferred Brand
and Specialty Drugs

Platinum $20 $50 $150
Gold $40 $80 $180
Low Gold $50 $100 $375
Silver A $60 $120 $300 after deductible 
Silver A II $60 $120  $300 after deductible 
Silver B $60 after deductible 35% after deductible  35% after deductible 
Bronze $60 $120 after deductible  $375 after deductible 

You can also view your prescription costs in the Prescription Drug section of Schedule of Benefits. You can find the tier of a prescription drug by searching our Drug Finder.

ConnectorCare and Qualified Health Plan members may be exempt from paying a copayment for the following reasons:

  • The member is receiving family planning supplies and/or family planning services
  • The member has met the annual out-of-pocket maximum when applicable

You can register/log in to envisionrx.com to find the cost of a specific drug.

Glossary 

Generics - You will pay the lowest copayment for generic drugs. Generics are equivalent to their brand-name counterparts, and are ensured by the Food and Drug Administration to be as safe and effective. 

Preferred Drug These are drugs covered by your pharmacy benefit when generic equivalents are not available.

Non-Preferred Drug - These are brand-name drugs that are not covered under your pharmacy benefit but may be covered if they are a part of your medical benefit, another preferred drug is tried first, or prior approval is obtained

For more definitions of frequently used healthcare terms, click here

 

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