Mass. Gen. Laws ch. 118E, sec. 10X — MA Code / Part I / Title XVII / Chapter 118E / Section 10X
Coverage for prescribed, ordered or dispensed opioid antagonists
Status: in_force

Section 10X. (a) The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan shall provide coverage for prescribed, ordered or dispensed opioid antagonists, as defined in section 19B of chapter 94C and used in the reversal of overdoses caused by opioids; provided, however, that the coverage for such prescribed, ordered or dispensed opioid antagonists shall not require prior authorization; and provided further, that a prescription from a health care practitioner shall not be required for coverage or reimbursement of opioid antagonists under this section. An opioid antagonist used in the reversal of overdoses caused by opioids shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits. (b) The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan shall provide coverage and reimbursement for an opioid antagonist used in the reversal of overdoses caused by opioids as a medical benefit when dispensed by the health care facility in which the opioid antagonist was prescribed or ordered and shall provide coverage as a pharmacy benefit for an opioid antagonist used in the reversal of overdoses caused by opioids dispensed by a pharmacist, including an opioid antagonist dispensed pursuant to section 19B of chapter 94C; provided, however, that the rate to be reimbursed under the medical benefit shall not exceed the carrier's average in-network pharmacy benefit rate and the health care facility shall not balance bill the patient.

Section 10X. (a) The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan shall provide coverage for prescribed, ordered or dispensed opioid antagonists, as defined in section 19B of chapter 94C and used in the reversal of overdoses caused by opioids; provided, however, that the coverage for such prescribed, ordered or dispensed opioid antagonists shall not require prior authorization; and provided further, that a prescription from a health care practitioner shall not be required for coverage or reimbursement of opioid antagonists under this section. An opioid antagonist used in the reversal of overdoses caused by opioids shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits.

(b) The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan shall provide coverage and reimbursement for an opioid antagonist used in the reversal of overdoses caused by opioids as a medical benefit when dispensed by the health care facility in which the opioid antagonist was prescribed or ordered and shall provide coverage as a pharmacy benefit for an opioid antagonist used in the reversal of overdoses caused by opioids dispensed by a pharmacist, including an opioid antagonist dispensed pursuant to section 19B of chapter 94C; provided, however, that the rate to be reimbursed under the medical benefit shall not exceed the carrier's average in-network pharmacy benefit rate and the health care facility shall not balance bill the patient.