Drug Costs
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.
|
Supply Type |
Tier 1
For generic high blood pressure, high
|
Tier 1
For all other generic |
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. Or to find the exact cost of a medication, login to the member portal.
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.
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.
|
Plan Name |
Tier 1 Generic Drugs |
Tier 2 Preferred Brand |
Tier 3 Non-Preferred |
| 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 |
| Plan Name
|
Tier 1 Generic Drugs |
Tier 2 Preferred Brand |
Tier 3 Non-Preferred |
| 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 log in to the member portal 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 |
Tier 3 Non-Preferred Brand |
| 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 |
| Plan Name
|
Tier 1 Generic Drugs |
Tier 2 Preferred Brand |
Tier 3 Non-Preferred Brand |
| 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 log in to the member portal to find the cost of a specific drug.