Section 7: Pharmacy Services
7.1 Pharmacy Contacts for Providers
| Where to Turn | Resource / Contact |
|---|---|
| To find out if a medication is covered | Our website (formulary) or Our pharmacy benefits manager at 800-510-8980 |
| For all prior authorization forms and clinical guidelines/criteria | Our
websiteor Our pharmacy benefits manager at 800-510-8980 |
| For dosing increases, replacement medication or vacation supply | Our pharmacy benefits manager at 800-510-8980 |
| For information on mail-order benefit / maintenance drug program | Our pharmacy benefits manager at 800-510-8980 |
| Information on office-administered drugs (i.e., injectables) that require prior authorization | Our website or Our provider service telephone line |
| Information on medications excluded from the benefit | Section 13 of this manual |
7.2 Overview
The Pharmacy Services department operates together with Health Services as an integral component of the Office of Clinical Affairs. To ensure that our members receive quality, affordable healthcare, we contract with a pharmacy benefit manager (PBM) to provide a pharmacy network and design the pharmacy benefits. Our pharmacy management programs offer comprehensive utilization management and reflect our clinical expertise. Section 7 outlines the many ways Pharmacy Services contributes to the Plan’s overall goal of keeping our members healthy.
7.3 Pharmacy and Therapeutics Committee
The Pharmacy and Therapeutics Committee (P&T Committee) is composed of internal and external actively practicing physicians, pharmacists and other practitioners. The Committee develops and manages the Plan’s drug formulary to reflect current evidence-based clinical practice, and for complying with all applicable legal, regulatory and accreditation standards.
In addition, the Committee evaluates the most current medical literature and consults with appropriate practitioners to develop clinical coverage criteria used to administer our pharmacy utilization management programs. These programs include prior authorization, step-therapy edits, and quantity limitations. Clinical coverage criteria are updated annually and approved by the P&T Committee.
The P&T Committee may also advise the Plan on other pharmacy-related issues as required to improve the overall delivery of the pharmacy benefit to our members and to enhance the quality of the pharmacy management program.
7.4 Drug Utilization Evaluation Program
Upon the recommendations of the P&T Committee, Pharmacy Services can perform an ongoing drug use evaluation of physician prescribing patterns, pharmacist dispensing activities, and member use of medications. This involves a comprehensive review of members’ prescription and medication data before, during and after dispensing to ensure appropriate medication decision-making and positive member outcomes. We may then recommend interventions to physicians, pharmacists and members, as necessary. To determine effectiveness, the P&T Committee also monitors utilization and compliance with the identified interventions.
7.5 Controlled Substance Management Program
The Controlled Substance Management Program (CSMP) seeks to improve the management of clinical conditions requiring therapy with controlled substance medications. Members are identified for the program through an interdisciplinary approach including medical and pharmaceutical claims. The member’s files are then reviewed, evaluated, and assigned to appropriate interventions. Interventions are intended to improve the quality of life for identified members; examples include assignments to care managers for care coordination, or prescription management by one primary pharmacy, physician or physician group.
The CSMP is lead by clinical pharmacists and includes collaboration with a multidisciplinary team of healthcare professionals that work together to outreach to members and/or providers to promote better clinical management of the member’s condition(s). Through this collaboration of clinicians, members are afforded a variety of resources with the goal of improving the quality and coordination of their care.
In addition to regular identification for enrollment, the CSMP also enrolls members through provider referrals. You may call the provider line and choose the pharmacy option to learn more about the CSMP and to enroll a member.
7.6 Pharmacy Networks Affiliated with the Plan
7.6.1 Pharmacy Benefit Manager (PBM)
Our pharmacy benefit manager (PBM) administers our prescription drug benefits. This includes making a comprehensive network of retail pharmacies available to our members. The Pharmacy page at bmchp.org contains a list of retail pharmacies affiliated with the PBM.
7.6.2 Specialty Pharmacy Networks
We contract with a network of specialty pharmacies with experience managing the dispensing of specific medications used to treat certain complex conditions. Visit the Plan formulary on our website for the most up-to-date information.
7.6.3 Mail Order Pharmacy
We arrange with our PBM to offer maintenance medications (three months at a time) through the mail for our members. This saves members time, effort and money. Some maintenance medications are not offered through this benefit, such as over-the-counter products, controlled substances and specialty medications.
Visit our website for more information about this benefit. To verify which medications are available by this mail order benefit, please call our PBM at 1-800-510-8980.
7.7 Pharmacy Benefits
7.7.1 The Plan Formulary
Our formulary is the primary source of information on medications available through the prescription pharmacy benefit for the MassHealth, Commonwealth Care and Commercial plans. The formulary contains information on medication coverage, availability, and copayment tier status. Please use the formulary as a reference when prescribing medications to Plan members. We regularly update the formulary with new medications and medication coverage changes. Changes to the Plan’s formulary are also mailed to our provider network as needed. The formulary is available through the Pharmacy page of our website: bmchp.org. If a medication requires prior authorization, the corresponding clinical criteria and prior authorization forms also can be accessed through the Pharmacy page on our website.
7.7.2 Over-the-Counter Products
Over-the-counter (OTC) coverage includes many commonly used over-the-counter medications and select medical devices that are available through the retail pharmacy network for MassHealth and Commonwealth Care members.Generic medications and devices that are explicitly listed on the OTC formulary are covered through the OTC benefit. A prescription must be written for the covered item so that it can be processed as a pharmacy claim. Medications on the OTC formulary are covered at the lowest copay for both MassHealth and Commonwealth Care members.
Select medical devices listed on the OTC formulary are covered for our Commercial plan members. Please see the OTC formulary at bmchp.org for details.
7.8 Pharmacy Management Programs
The Pharmacy Management programs are designed to manage the utilization of drugs that can be obtained through retail pharmacies, specialty pharmacies, or in a provider setting. These programs include quantity limits, step therapy, mandatory generics, prior authorization, and new-to-market medication restrictions. Medications managed with any of these programs require submission of a Prior Authorization Form. A utilization review decision will be rendered on the coverage of the requested medication. These programs are updated regularly, based on our P&T Committee’s recommendations, and reflect the ever-changing field of pharmaceuticals.
Visit bmchp.org for the most up-to-date medication coverage information, clinical guideline/criteria, and prior authorization form, or call the Plan’s PBM at 1-800-510-8980. For more information about authorizations, see section 7.8.4 and section 3.
If we deny a pharmacy prior authorization request, the member and his or her authorized appeal representative have the right to appeal the decision. If you or your authorized representative appeals this decision, you have the right to submit any additional information that you would like us to consider during the internal appeal process. An internal appeal must be submitted within 30 calendar days for MassHealth and 180 calendar days from the date of the letter for Commonwealth Care and Commercial plans. See section 10for additional information on appeals, inquiries, and grievances.
Below are descriptions of the Pharmacy Management programs.
7.8.1 Quantity Limitation Program
The Quantity Limitation program ensures the safe and appropriate use of a select number of medications by covering only a specified amount of the medication to be dispensed at any one time. Quantities greater than the specified amount dispensed at any one time require prior authorization for coverage.
See the Pharmacy page at bmchp.org under Pharmacy Programs for a listing of medications that are on the Quantity Limitation Program.
7.8.2 Step Therapy Program
A step-therapy approach to care requires the use of a recognized first-line drug before approval of a second-line drug is granted. Step therapy is a safe, effective method to reduce the cost of treatment by ensuring that a proven, cost-effective therapy is tried before progressing to a more costly remedy. If the required therapeutic benefit is not achieved using the first-line drug, the prescriber may request the use of a second-line medication. Step therapies are appropriate under two conditions:
- When the existing therapies in a certain class are considered equivalent but there is a difference in price
- When standard protocols and published guidelines indicate step therapy as a best practice standard
See the Pharmacy page at bmchp.org under Pharmacy Programs to access the prior authorization form.
7.8.3 Mandatory Generic Medication Program
The US Food and Drug Administration (FDA) has determined certain generic medications to be therapeutically equivalent (“AB rated”) to their brand counterparts. This means that these generic medications are as effective as the brand. Massachusetts requires dispensing “AB rated” generic unless the practitioner indicates that the brand medication is medically necessary. In addition, coverage for a brand medication must meet the Plan’s clinical criteria.
See the Pharmacy page at bmchp.org under Pharmacy Programs to access the prior authorization form.
7.8.4 Pharmacy Prior Authorization Program
We apply clinical guidelines/criteria for coverage to some medications that are dispensed through either the retail pharmacy or provider setting. The clinical guidelines and criteria often require that patients have certain diagnoses or clinical conditions and meet specific guidelines for treatment before we will authorize a medication for coverage.
If you feel it is medically necessary for a member to take a drug managed under our programs, submit the appropriate prior authorization request form to the fax number or destination indicated on the form. See the Pharmacy page at bmchp.org to access the form. A clinician will review your request, and we will notify you of the decision in accordance with applicable regulatory and accreditation standards.
7.8.5 New-to-Market Medication Program
We review all new-to-market drugs before adding them to the formulary or covering them under our pharmacy benefits. The P&T Committee evaluates these drugs to determine whether the new-to-market medications are safe for prescribing to members, and to determine the coverage status.
See the Pharmacy page at bmchp.org under Pharmacy Programs to access the prior authorization form.
7.8.6 Medication Exception Process
The medication exception process allows a member the ability to request coverage of a non-covered medication based upon medical necessity. Medications specifically excluded from coverage by federal or state regulations (such as Medicaid), and those specifically excluded in the Commonwealth Care and Commercial plans Evidence of Coverage are not subject to this policy.
You must submit to us a letter of medical necessity, along with any corresponding documentation relevant to the medical necessity of the non-covered medication.
7.9 Pharmacy Copayments
7.9.1 Member Cost Sharing Amounts
Plan members with MassHealth, aged 19 and older, and Commonwealth Care members are charged a copayment for medications.
Commercial plan members are charged copayments, coinsurance and/or deductibles for medications, and may have special pharmacy deductibles – depending on the applicable benefit package in which they are enrolled.
Some non-Commercial Plan members may be eligible for a copayment exemption if they meet certain criteria. See section 13for details.
7.9.2 Annual Cost-Sharing Caps
MassHealth and Commonwealth Care members are responsible for paying copayments for all dispensed medications, including retail, specialty and mail-order, until they have reached their annual copayment “cap” or maximum. Members become exempt from paying copayments once they have reached the maximum. See Section 13for details.
Commercial Plan members may be protected by out-of-pocket maximums that may include deductibles, copayments or coinsurance paid by the member for medications. See section 13for details.
We send a letter to each member notifying him or her when the annual maximum is reached. If a member believes he or she has reached the annual maximum at an earlier date than we have documented, the member should submit a completed Member Reimbursement Claim Form with copies of receipts for the cost sharing (deductibles, copayments and coinsurance) paid. This form can be obtained through our Member Services department or at bmchp.org. If the member does not have receipts for all the amounts paid, he or she may request a prescription and cost-sharing record from their servicing pharmacy.
7.9.3 Pharmacy Copayment Compliance
All pharmacies are expected to comply with the cost-sharing rules applicable to all plans.
Commonwealth Care and Commercial plan members: Pharmacies must collect the required deductible, copayment and/or coinsurance. Check the specific Plan benefits for clarification in section 13.
Re: MassHealth members: In accordance with 130 CMR 450.130, providers, including pharmacies, may not refuse services or withhold prescriptions if the member reports he/she is unable to pay the copayment at the time of service/receipt of prescription.
7.9.4 Plan Action with Non-Compliant Pharmacies for MassHealth Members
Our Pharmacy staff will immediately follow up with any pharmacy that denies a medication to a MassHealth member based on the member’s reported inability to pay the pharmacy copayment. Our standard operating procedure includes:
- Outreach to the member who was denied the medication to ensure that he or she receives the needed medication in a timely manner.
- Informing the pharmacy that denying prescription drugs to MassHealth members based on a member’s inability to pay his/her copayment is a violation of MassHealth regulations and federal Medicaid law.
- Providing MassHealth with a list of pharmacies that demonstrate a pattern of inappropriately denying prescription drugs to members, and documenting steps the Plan takes to resolve the situation.
- If necessary, taking disciplinary action against a noncompliant pharmacy.
