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Member Copayment Information

Updated copayment information for MassHealth Members

A copay is a small amount that a person pays 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 updated copayment information for MassHealth Members.

 

For copay information related to COVID-19 treatment and services, please visit https://www.mass.gov/info-details/masshealth-coronavirus-disease-2019-covid-19-applicants-and-members#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.

 

Please note that 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.

Current Copay Cap

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

There is a $250 calendar year copay cap for pharmacy services.

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

Upcoming Copay Cap Changes

Starting July 1, 2021, MassHealth is making changes so that your copays will not be more than 2% of your monthly household income.  Also, during the Federal COVID-19 Public Health Emergency, you will not be charged more than $250 in total copays annually. The information below explains how MassHealth will calculate this new monthly copay cap.

  • A copay cap is the highest dollar amount that you can be charged in copays in a month.
  • MassHealth will calculate a monthly copay cap for you based on the lowest income in your household and your household size, as applicable. MassHealth will round your copay cap down to the nearest ten-dollar increment. No copay will be more than $60. The following table shows that 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 Greater

$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.

In addition, starting July 1, 2021, the amount you pay each month for your health coverage (your premium) will not exceed 3% of your monthly household income. This limit does not apply to CommonHealth members.

Upcoming Copay Cap Notifications

Starting May 2021, MassHealth will send you a letter explaining these changes and notifying you of your initial monthly copay cap amount. Starting July 2021, MassHealth will review your account and will send you a letter when you get a new monthly copay cap or whenever 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. See contact information below.

Member Exclusions

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,
  • You are eligible for MassHealth because you are getting 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 130 CMR 506.015 and 130 CMR 520.037,
  • You are under 21 years old,
  • You are pregnant or or your pregnancy has recently ended you are in a postpartum period,
    • MassHealth defines the postpartum period as the time through the last day of the second calendar month after the end of the member's pregnancy. (For example, if the member gave birth on May 15th, the postpartum period ends July 31st).
  • You are getting benefits under MassHealth Limited (emergency MassHealth),
  • You are a member with MassHealth Senior Buy-In or MassHealth Standard, and you are getting 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 nursing facilities, chronic-disease or rehabilitation hospitals, or intermediate-care facilities for individuals with intellectual disabilities or who are admitted to a hospital from such a facility or hospital,
  • You are getting receiving hospice services,
  • You were a foster care child and you are eligible for MassHealth Standard, until age 21 or 26 as specified by 130 CMR 505.002(H),
  • You are American Indian or an Alaska Native currently receiving or have ever received services at the Indian Health Service, an Indian tribe, a tribal organization, or an urban Indian organization, or
  • You are in another exempt category (see 130 CMR 506.015 or 130 CMR 520.037).

 

In addition, there is no copay for the following services:

  • Substance Use Disorder (SUD) treatment, such as Medication-Assisted Therapy (MAT) (for example, Suboxone or Vivitrol),
  • Certain preventive drugs such as low-dose aspirin for heart conditions, drugs used for HIV prevention, and drugs used to prepare for a colonoscopy,
  • Certain vaccines and their administration,
  • Family planning supplies,
  • Products and 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. You should never go without covered drugs or treatment that you need because you cannot afford the copay. 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.

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