Prescription Costs

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 copayment.

  Tier 1 Tier 2 Tier 3


Supply Type

New Hampshire Medicaid 
New Hampshire Medicaid 
All Other Well Sense
Covered Drugs


(1-Month Supply)








(3-Month Supply)







You will not have to pay a copayment 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

*Pharmacies may not refuse to fill your prescription if you can’t pay the fee. However, the pharmacist may bill you for the fee.

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2021 Drug List

2021 Pharmacy Changes


New for 2021! Starting in January we're updating our Pharmacy Benefits to help improve your overall member experience. View our member FAQs for more information.

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See if a Drug is Covered 

What's the difference between a generic and brand-name drug?


When a company makes a new drug for the first time, they are the only ones who can sell it for a certain number of years. This is a brand-name drug. After that time, other companies can make and sell the same drug under a different name, making it a generic drug.