Copay cap

Members are responsible for MassHealth pharmacy copays up to a monthly limit, called a copay cap, not to exceed 2% of the member’s monthly household income.

  • A copay cap is the highest dollar amount that members can be charged in pharmacy copays in a month.
  • MassHealth calculates a monthly copay cap for each member based on the lowest income in their household and their household size. MassHealth rounds the copay cap down to the nearest $10 amount. No copay will be more than $60.

The following table shows what the member’s final monthly copay cap will be:

If the member's monthly copay cap is calculated to be: The member's 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 more $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.

Members do not need to pay any more pharmacy copays once they have reached their pharmacy copay cap for the month. MassHealth will send members a letter when they reach the monthly copay cap. If the pharmacy tries to charge the member any more copays for that month, the member should show the pharmacy the letter and the pharmacy should not charge the copay.

Members who do not receive a letter, or who have any questions, should call Tufts Health Plan member services at 888-275-1985 (TTY: 711).