Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 406.000 - Pharmacy Services
Section 406.404 - Provider Eligibility

(1) have a retail establishment located and doing business in the Commonwealth of Massachusetts;

(2) be licensed by the Massachusetts Board of Registration in Pharmacy in accordance with M.G.L. c. 112, and 247 CMR 6.00: Registration, Management and Operation of a Pharmacy or Pharmacy Department or be licensed by the Massachusetts Department of Public Health as a pharmacy in a clinic setting in accordance with M.G.L. c. 111;

(3) be licensed by the federal Drug Enforcement Administration (DEA) and possess a DEA registration number (if a pharmacy is licensed to dispense only Schedule VI drugs, the pharmacy may possess a Massachusetts Controlled Substance Registration number instead of a DEA registration number); and

(4) agree to use the MassHealth Pharmacy Online Processing System (POPS) in real-time mode to submit claims.

(1) All Out-of-state Providers. A provider that does not meet the requirements of 130 CMR 406.404(B) may participate in MassHealth only if the provider meets the following requirements of 130 CMR 450.109: Out-of-state Services; and

(2) Limited Purpose Out-of-state Providers.

(1) Notification of Participation. Except for drugs that cost $100,000 or more (gross cost per utilizer per year) that are designated as excluded from coverage for MassHealth members through the 340B Drug Pricing Program, a 340B-covered entity may provide drugs to MassHealth members through the 340B Drug Pricing Program, provided that it notifies the MassHealth agency by submitting to the MassHealth agency in writing that the 340B-covered entity is registered and approved by the federal Office of Pharmacy Affairs (OPA). Any high cost drug designated for exclusion from coverage for MassHealth members through the 340B drug pricing program will be communicated by provider bulletin or other written issuance from the MassHealth agency, be consistent with all requirements of M.G.L. c. 118E, §13L, and include an opportunity for eligible providers to provide input regarding the designation. The MassHealth agency may designate up to 25 drugs for exclusion from coverage for MassHealth members through the 340B Drug Pricing Program. Any exclusion from coverage for MassHealth members through the 340B Drug Pricing Program does not apply to claims paid using the adjudicated payment amount per discharge (APAD) or adjudicated payment per episode of care (APEC) methodology, other than for drugs listed on the Acute Hospital Carve-Out Drugs List section in the MassHealth Drug List.

(2) Subcontracting for 340B Outpatient Pharmacy Services.

(3) Termination or Changes in 340B Drug-pricing Program Participation. A 340B-covered entity must provide the MassHealth agency 30 days' advance written notice of its intent to discontinue, or change in any way material to the MassHealth agency, the manner in which it provides 340B outpatient drugs for its MassHealth patients.

(4) Payment for 340B Outpatient Pharmacy Services. The MassHealth agency pays the 340B-covered entity for eligible pharmacy services, whether provided and billed directly or through a subcontractor, at the rates established in 101 CMR 331.00: Prescribed Drugs.