Depending on your age and other factors listed below, you may need to pay a small fee (of $1) per covered prescription.* This fee is also called a copay.

Type Tier 1
New Hampshire Medicaid Preferred Drugs
Tier 2
New Hampshire Medicaid Non-Preferred Drugs
Tier 3
All other WellSense New Hampshire Medicaid Covered Drugs
(1-month supply)
$1.00 $1.00 $10.00

Mail Order
(3-month supply)

$1.00 $1.00 $1.00
You will not have to pay a copay if:
  • You fall under the designated income threshold (100% or below the federal poverty level);
  • You are under age 18 years;
  • You are in a nursing facility or in an intermediate-care facility for individuals with intellectual disabilities;
  • You participate in one of the Home and Community-Based Care (HCBC) waiver programs;
  • You are pregnant and receiving services related to your pregnancy or any other medical condition that might complicate your pregnancy;
  • You are receiving services for conditions related to your pregnancy and your prescription is filled or refilled within 60 days after the month your pregnancy ended;
  • You are in the Breast and Cervical Cancer program;
  • You are receiving hospice care; or
  • You are a Native American or Alaska native
*Pharmacies may not refuse to fill your prescription if you can’t pay the fee. However, the pharmacist may bill you for the fee.