Pharmacy and Prescription Benefits

A “copayment” or “copay” is the fixed amount you may pay each time you fill and refill a prescription. Prescription drug copayment amounts are subject to change.

Prescription drug copayments are $4.

If you have any questions about copayments, please call Member Services at 1-833-704-1177 (TTY 1-855-534-6730), 24 hours a day, seven days a week.

You do 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.
• You are in a nursing facility or in an intermediate care facility for people with intellectual disabilities.
• You use one of the Home and Community Based Care (HCBC) waiver programs.
• You are pregnant and using services related to your pregnancy or any other medical condition that might complicate your pregnancy.
• You are using services for conditions related to your pregnancy and your prescription is filled or refilled within 12 months after the month your pregnancy ended.
• You are in the Breast and Cervical Cancer Program.
• You are receiving hospice care.
• You are a Native American or an Alaska Native.

If you believe you may qualify for any of these exemptions and are charged a copayment, contact New Hampshire Department of Health and Human Services (NH DHHS) Customer Service Center toll-free at 1-844-ASK-DHHS (1-844-275-3447) (TDD Relay Access: 1-800-735-2964), Monday through Friday, 8 a.m. to 4 p.m. ET.

Show your AmeriHealth Caritas New Hampshire member ID card when you get your prescription. If you need a member ID card or don’t have your ID Card, please call Member Services at 1-833-704-1177 (TTY 1-855-534-6730), 24 hours a day, seven days a week. 

Some medications on the preferred drug list and all medications not on the list need prior authorization. If your doctor writes a prescription for a medication that needs prior authorization, they will need to send us a prior authorization request. We will review it and let you and your doctor know our decision.

We will cover the medication if it is medically needed. If it is not, we will send you and your doctor a letter telling why it is not approved. We will also let you know which other medicines or therapies may be used. The letter will tell you how to appeal if you want to do so.

If you have questions about appealing a decision, call Member Services at 1-833-704-1177 (TTY 1-855-534-6730), 24 hours a day, seven days a week. 

Some medications may have monthly limits on the amount and number of times they can be refilled. This is shown in the preferred drug list. To ask for a prescription limit override, the doctor who prescribed the medication or your pharmacist should call Pharmacy Provider Services:  1-888-765-6394.

In some cases, we need you to try certain medications first before we can cover another medication for the same condition. For example, if medication A and medication B both treat your condition, we may not cover medication B unless you try medication A first. If your doctor says that medication A does not work for you, we may cover medication B with prior authorization from your doctor.  

The preferred drug list shows which drugs this applies to. 

Sometimes your medication may need prior authorization, but you need to start it right away. Your pharmacy can give you a three-day emergency supply. In some cases, your pharmacist may not give you the three-day supply if they feel it is not safe for you to take it.

Our lock-in program prevents members from overusing certain types of medications. As part of this program, we review all medications that members take. When we find overuse of certain medications, we can restrict members to a single pharmacy. A member can choose their pharmacy, or one may be chosen for them.

If you have questions on the pharmacy lock-in program call Member Services at 1-833-704-1177 (TTY 1-855-534-6730), 24 hours a day, seven days a week

We do medication reviews for our members to help make sure that medications aren’t interacting in an unsafe way. These reviews are very important for members who get their medications from more than one prescriber or have more than one medication.

We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for possible problems such as:

• Medication errors
• Medications that may not be needed because you are taking another medication to treat the same condition
• Medications that may not be safe or right for you because of your age or gender
• Combinations of medications that could harm you if taken at the same time
• Medications that have ingredients you are allergic to
• Errors in the amount (dosage) of a medication you are taking

If we see a possible problem in your use of medications, we will work with your provider to correct the problem.

If you have any questions about medication reviews, call Pharmacy Member Services at 888-765-6383 (TTY 711), 24 hours a day, seven days a week.