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.
Exemptions apply to MassHealth members only, unless noted otherwise.
-
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. All MassHealth and
Commonwealth Care members
.
-
The member is receiving family planning supplies and/or family planning
medication in a physician office. MassHealth and Commonwealth Care plan
type I members only.
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.
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:
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.
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