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MassHealth Copay Information – For Members

Updated copay information for MassHealth members

A copay is a small amount that a person may need to pay when they get health services. The only time that you may have a copay is when you get certain prescription drugs. There are no copays for other MassHealth covered services. Below is more information on copays for MassHealth members.

For copay information related to COVID-19 treatment and services, please see the Frequently Asked Questions for Members and Applicants.

 

Table of Contents

MassHealth Copays

Pharmacy copays for drugs covered by MassHealth, including both first-time prescriptions and refills, are

  • $1 for certain covered generic drugs and over-the-counter drugs mainly used for diabetes, high blood pressure, and high cholesterol. These drugs are called antihyperglycemics (such as metformin), antihypertensives (such as lisinopril), and antihyperlipidemics (such as simvastatin); and
  • $3.65 for each prescription and refill for all other generic, brand-name, and over-the-counter drugs covered by MassHealth.

If you are receiving a 90-day supply of a MassHealth covered prescription drug, the total copay amount for that 90-day supply will either be $1 or $3.65 depending on the type of drug as outlined above

Copay Cap

A copay cap is the highest dollar amount that a person can be charged in copays for a given time period.

You will be given a copay cap by MassHealth. This copay cap will not be more than 2% of your monthly household income each month. During the federal COVID-19 public health emergency, you will not be charged more than $250 in total copays in one year.

How MassHealth Determines the Copay Cap

MassHealth calculates a monthly copay cap for you based on the lowest income in your household and your household size. MassHealth rounds your copay cap down to the nearest $10 amount. No copay cap will be more than $60.

The following table shows what your monthly copay cap will be:

 

If your monthly copay cap is calculated to be:

Your final monthly copay cap will be:

$0 to $9.99

No Copays

$10 to $19.99

$10

$20 to $29.99

$20

$30 to $39.99

$30

$40 to $49.99

$40

$50 to $59.99

$50

$60 or More

$60

For example, if your monthly copay cap is $12.50 in July, you will not be charged more than $10 of copays in July. If your household income or family size changes in August, your monthly copay cap may change for August.

Each family member must meet their own cap. Once you have been charged the maximum in copays during a given month, you will no longer have to pay copays until the next month.

In addition, the amount you pay each month for your health coverage (your premium) will not be more than 3% of your monthly household income. This limit does not apply to CommonHealth members.

For more information on premiums, please go to the Premium Information – For Members webpage.

Copay Cap Notifications

If you want to know your copay cap amount, please call (800) 841-2900, select 1 for “member”, select your desired language, and then follow the prompts.

MassHealth will send you a letter when you reach your monthly copay cap. If you have questions about any letter you receive, or if you have questions about your copays, please call the MassHealth Customer Service Center at (800) 841-2900, TTH at (800) 497-4648.

Member Who Don’t have Copays

Some members don’t have to pay a copay at all. You do not have to pay a MassHealth copay for any service covered by MassHealth if:

  • Your income is at or below 50% of the federal poverty level (FPL)
  • You are eligible for MassHealth because you are receiving certain public assistance benefits such as Supplemental Security Income (SSI), Transitional Aid to Families with Dependent Children (TAFDC), or services through the Emergency Aid to the Elderly, Disabled and Children (EAEDC) Program. See regulations at 130 CMR 506.015 and 130 CMR 520.037
  • You are under 21 years old
  • You are pregnant or you’ve recently given birth (you’re in the postpartum period)
  • You are receiving benefits under MassHealth Limited (Emergency Medicaid)
  • You are a member who has MassHealth Senior Buy-In or MassHealth Standard, and you are receiving a drug that is covered under Medicare Parts A and B only, when provided by a Medicare-certified provider,
  • You are in a long-term care facility such as:
    • A nursing facility
    • Chronic-disease or rehabilitation hospital, or
    • Intermediate-care facility for individuals with intellectual disabilities
      or
    • You’ve been admitted to a hospital from such a facility or hospital
  • You are receiving hospice services
  • You were a foster care child and you are eligible for MassHealth Standard, until age 21 or 26 as described in regulations at 130 CMR 505.002(H),
  • You are American Indian or an Alaska Native and you are currently receiving or have ever received services at the Indian Health Service (IHS), an Indian tribe, a tribal organization, or an urban Indian organization, or
  • You are in another exempt category (see regulations at 130 CMR 506.015 or 130 CMR 520.037).

Services That Don’t have Copays

In addition, there are no copays for the following services:

  • Drugs used to treat substance use disorder (SUD), such as medication-assisted therapy (MAT) (for example, Suboxone or Vivitrol)
  • Certain preventive drugs such as low-dose aspirin for heart conditions, drugs to prevent HIV, and drugs used to prepare for a colonoscopy
  • Certain vaccines and their administration
  • Family planning drugs or supplies, such as birth control pills (oral contraceptives)
  • Drugs to help you stop smoking
  • Emergency services, or
  • Provider preventable services

Your Rights

If you cannot afford the copay at the time you receive a covered drug, tell your pharmacy. The pharmacy must still provide you with covered drugs even if you cannot afford to pay the copay. However, the pharmacy can still bill you for the copay.

You should never go without covered drugs or treatment that you need because you cannot afford the copay. 

Frequently Asked Questions

What is a copay and what is a copay cap?

A copay is a small amount that a person pays when they get health services. A copay cap is the highest dollar amount that a person can be charged in copays in a month.

How much is my copay cap?

You will be given a monthly copay cap by MassHealth and this copay cap will not be more than 2% of your monthly household income each month. MassHealth will calculate a monthly copay cap for you based on the lowest income in your household and your household size, as applicable. Please see the Copay Cap section, above, for more information on how MassHealth calculates this copay cap.

Please note that during the federal COVID-19 public health emergency, you will not be charged more than $250 in total copays in a year.

What happens if my income, household size, or other circumstances change? Will my copay cap change?

If your income, household size, or other circumstances change, your monthly copay cap may change. You must report any changes to MassHealth within 10 days of a change or as soon as possible.

To report changes, please call the MassHealth Customer Service Center at (800) 841-2900, TTH at (800) 497-4648. Members under the age of 65 who have a HIX account may report changes by using the change feature and the document upload feature.

What happens when I meet my copay cap?

You will not have to pay copays for covered drugs once you hit your copay cap for the rest of the month. MassHealth will send you a letter once you meet your current monthly copay cap.

How I know if I have met my copay cap?

MassHealth will send you a letter once you meet your current monthly copay cap.

Am I exempt from copays?

If you fall under one of the categories in the Members Who Don’t have Copays section, above, you do not have to pay copays. In addition, if you are receiving a service under the Services That Don’t have Copays section, you do not have to pay a copay for those services.

What if I cannot afford my copay?

If you cannot afford the copay when you receive a covered drug, tell your pharmacy. The pharmacy must still provide you with covered drugs even if you cannot afford to pay the copay. However, the pharmacy can still bill you for the copay.

You should never go without covered drugs or treatment that you need because you cannot afford the copay. 

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