Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.414 - Insurance Coverage

Current through Register 1525, July 5, 2024
(A)
Managed Care Organizations
. The MassHealth agency does
			 not pay pharmacy claims for services to MassHealth members enrolled in a
			 MassHealth managed care organization (MCO) that provides pharmacy coverage
			 through a pharmacy network or otherwise, except for family planning pharmacy
			 services provided by a non-network provider to a MassHealth MCO enrollee (where
			 such provider otherwise meets all prerequisites for payment for such services).
			 A pharmacy that does not participate in the MassHealth member's MCO must
			 instruct the MassHealth member to take his or her prescription to a pharmacy
			 that does participate in such MCO. To determine whether the MassHealth member
			 belongs to an MCO, pharmacies must verify member eligibility and scope of
			 services through POPS before providing service in accordance with
			 130
			 CMR 450.107:
Eligible Members and the
			 MassHealth Card
and
			 130
			 CMR 450.117:
Managed Care
			 Participation
.
(B)
Other Health Insurance.
When the member's primary
			 carrier has a preferred drug list, the prescriber must follow the rules of the
			 primary carrier first. The provider may bill the MassHealth agency for the
			 primary insurer's member copayment for the primary carrier's preferred drug
			 without regard to whether the MassHealth agency generally requires prior
			 authorization, except in cases where the drug is subject to a pharmacy service
			 limitation pursuant to
			 130
			 CMR 406.413(C)(2)(a). In
			 such cases, the prescriber must obtain prior authorization from the MassHealth
			 agency in order for the pharmacy to bill the MassHealth agency for the primary
			 insurer's member copayment. For additional information about third-party
			 liability,
see
130 CMR 450.101:
Definitions
.
(C)
Medicare Part D
.
(1)
Overview
. Except as otherwise required in
			 130
			 CMR 406.414(C)(2) and (3),
			 for MassHealth members who have Medicare, the MassHealth agency does not pay
			 for any Medicare Part D drugs, or for any cost-sharing obligations (including
			 premiums, copayments, and deductibles) for Medicare Part D drugs, whether or
			 not the member has actually enrolled in a Medicare Part D drug plan.
			 Medications excluded from the Medicare Part D drug program continue to be
			 covered for MassHealth members eligible for Medicare, if they are
			 MassHealth-covered medications.
(2)
Medicare Part D One-time Supplies
. The MassHealth
			 agency pays for one-time supplies of prescribed medications, as described in
			 130
			 CMR 406.414(C)(2), if the
			 medication is a MassHealth-covered medication and the MassHealth member would
			 otherwise be entitled to MassHealth pharmacy benefits, but for being eligible
			 for Medicare prescription drug coverage. MassHealth prior authorization does
			 not apply to such one-time supplies. The MassHealth agency pays for the
			 one-time supplies in all instances in which the pharmacist cannot bill a
			 Medicare Part D prescription drug plan at the time the prescription is
			 presented. The MassHealth agency pays for a one-time 72-hour supply of
			 prescribed medications.
(3)
Cost-sharing Assistance for MassHealth Members Enrolled in a
			 Medicare Part D Prescription Drug Plan
. For the purpose of
			 130
			 CMR 406.414(C)(3), the
			 "applicable MassHealth copayment" is the copayment the MassHealth member would
			 pay for prescription drugs if the drugs were covered by MassHealth and not
			 covered by Medicare Part D. MassHealth members who are enrolled in a Medicare
			 Part D prescription drug plan and are charged a copayment or deductible in
			 excess of the member's applicable MassHealth copayment for a drug that
			 MassHealth would otherwise cover, must pay the applicable MassHealth copayment,
			 and the MassHealth agency pays the difference between the applicable MassHealth
			 copayment and the amount charged by the Medicare Part D prescription drug
			 plan.