MassHealth 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. Select your plan below to search the formulary.

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
Generic Drugs

Tier 2
All other generic and over-the-counter drugs

Tier 3
Covered brand drugs
Retail
(one-month supply)
$1.00 $3.65 $3.65
Mail order
(three-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 copay cap. This out-of-pocket copay is collected at the pharmacy at the time the prescriptions are filled. To find out what the copay tier of your medication, 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 copay for drugs for any of the following reasons:

  • The member is under age 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 Copay Cap

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

For MassHealth, the annual copay cap is $250.

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

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

Glossary

Generics - You will pay the lowest copay 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.

Nonpreferred 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.