Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.422 - Prior Authorization

Current through Register 1525, July 5, 2024
(A) Prescribers
			 must obtain prior authorization from the MassHealth agency for drugs identified
			 by MassHealth in accordance with
			 130
			 CMR 450.303:
Prior
			 Authorization
. If the limitations on covered drugs specified in
			 130
			 CMR 406.412(A)  and
			 130
			 CMR 406.413(A) and (C) would
			 result in inadequate treatment for a diagnosed medical condition, the
			 prescriber may submit a written request, including written documentation of
			 medical necessity, to the MassHealth agency for prior authorization for an
			 otherwise noncovered drug.
(B) All
			 prior authorization requests must be submitted in accordance with
			 130
			 CMR 450.303:
Prior
			 Authorization
and the instructions for requesting prior authorization
			 in the Pharmacy Online Processing System (POPS) billing guide, the MassHealth
			 Drug List, and any other applicable guidance. The MassHealth agency will notify
			 the requesting provider and the member, in writing, of its decision.
(C) The MassHealth agency will authorize at
			 least a 72-hour emergency supply of a prescription drug to the extent required
			 by federal law. (
See
42 U.S.C.
			 1396r-8(d)(5).) The
			 MassHealth agency acts on requests for prior authorization for a drug within a
			 time period consistent with federal regulations.
(D) Prior authorization does not waive any
			 other prerequisites to payment such as, but not limited to, member eligibility
			 or requirements of other health insurers.
(E) The MassHealth Drug List specifies the
			 drugs that are payable under MassHealth and designates which drugs require
			 prior authorization. Any drug that does not appear on the MassHealth Drug List
			 requires prior authorization. The MassHealth agency evaluates the prior
			 authorization status of drugs on an ongoing basis, and updates the MassHealth
			 Drug List accordingly.
(F) If the
			 pharmacy does not dispense a drug or non-drug product because the prescriber
			 did not submit a request for prior authorization, the pharmacy must take
			 reasonable steps to notify both the patient and prescriber of the need for
			 prior authorization, and make a contemporaneous record of having done
			 so.
(G) The MassHealth agency
			 allows exceptions to its step therapy protocol consistent with M.G.L. c.118E,
			 § 51A. The MassHealth Drug List details the specific process for members
			 or their prescriber seeking an exception to step therapy.
(1) The MassHealth agency will grant or deny
			 a request for an exception to the step therapy protocol or a request to appeal
			 a denial of an exception not more than three business days after the receipt of
			 all necessary information to establish the medical necessity of the prescribed
			 treatment. If additional delay would result in significant risk to the
			 enrollee's health or well-being, then this three-business day period will be
			 reduced to 24 hours after the receipt of all necessary information to establish
			 the medical necessity of the prescribed treatment.
(2) For purposes of
			 130
			 CMR 406.422(G)(1), an appeal
			 of a denial of a step therapy exception will occur through informal
			 consultation with a clinical pharmacist with the MassHealth program or its
			 utilization review organization.
(3) Nothing in this section shall limit a
			 member's right to a fair hearing consistent with the timing and requirements
			 under
			 130 CMR
			 610.00:
MassHealth: Fair Hearing
			 Rules
.
(4) For purposes of
			 granting exceptions to step therapy consistent with M.G.L. c. 118E, §
			 51A(c)(1)(iv)(a), MassHealth is not required to consider samples provided to
			 members absent a prescription to be a "prescription drug prescribed by the
			 healthcare provider" or otherwise sufficient to establish stability.
(5) Requests for exceptions to step therapy
			 require such documentation as MassHealth requires to establish the medical
			 necessity of the treatment or otherwise specifies on the MassHealth Drug
			 List.