*When your Network Health patients can get generic drugs, we will not cover the brand-name drug unless we give you prior authorization. If we approve the brand-name drug, MassHealth, Commonwealth Care Plan Type I, and Medical Security Program (MSP) Plan Type I patients will pay a brand-name drug (Tier 2) co-payment.

**The co-payment cap for MassHealth and MSP Plan Type I is effective from January 1 to December 31. The co-payment cap for Commonwealth Care Plan Type I is effective from July 1 to June 30. Co-payment caps are applicable to each individual enrolled in the plan.

***Pharmacy co-payments for covered generic and select over-the-counter drugs are $3.65. Certain covered generic and OTC medications in the following drug classes have a $1 co-payment: antihyperglycemics, antihypertensives, and antihyperlipidemics.

Products that do not require a co-payment

For your Network Health patients enrolled in Network Health Together^® (MassHealth), Network Health Forward^® (Commonwealth Care) Plan Type I, or Network Health Extend (Medical Security Program) Plan Type I, we cover with a prescription and no co-payment:

• Family-planning drugs and supplies 
• Humidifiers and vaporizers 
• Peak flow meters and spacers, for members with asthma 
• Supplies for members with diabetes

Patients who have MassHealth and Medicare coverage

For your Network Health patients who have MassHealth and Medicare coverage, their Medicare Prescription Drug Coverage (Part D) plan will cover most of their prescription drugs. Even though these patients have Medicare Part D, we will cover some drugs, such as select OTC drugs. The co-payment amounts we describe earlier still apply to these covered drugs.

Patients who do not have to pay co-payments

The following populations are exempt from pharmacy co-payments:  

Network Health Together patients

• American Indians and Alaskan Natives from federally recognized tribes (effective October 1, 2011)
• Patients under the age of 19
• Patients who were in the care of the Department of Children and Families (DCF) and whose MassHealth coverage continued after they turned 18

 All Network Health patients

• Women who are pregnant or whose pregnancy ended less than 60 days prior
• Patients in nursing facilities, immediate-care facilities for the developmentally delayed, or hospitals serving patients with acute, chronic-disease, or rehabilitation needs
• Patients in hospice care
• Patients who have reached their pharmacy co-payment cap for the calendar year (unless their eligibility changes from Plan Type I to Plan Type II or III)