Current through Register 1531, September 27, 2024
(A)
Introduction.
The MassHealth agency has established a Controlled Substance Management Program
for MassHealth members who over utilize or improperly utilize prescribed drugs.
Members in the Controlled Substance Management Program are restricted to
obtaining prescribed drugs only from the provider that the MassHealth agency
designates as the member's primary pharmacy.
(B)
Criteria for Member
Enrollment. The MassHealth agency may enroll in the Controlled
Substance Management Program those MassHealth members who meet one of the
following criteria:
(1) members whom the
MassHealth agency determines over-utilize or improperly utilize medications in
certain therapeutic classes, receive duplicative therapy from multiple
physicians, or frequently visit the hospital emergency department seeking pain
medications. The MassHealth Drug Utilization Program will identify criteria to
identify members for the Controlled Substances Management Program. These
criteria will be listed in the MassHealth Drug List; or
(2) members who were enrolled in the
Controlled Substance Management Program of a MassHealth-contracted managed care
organization (MCO) at the time the member disenrolled from the MCO. When the
MassHealth agency enrolls a member in the Controlled Substance Management
Program it notifies the member accordingly.
(C)
Service
Restriction.
(1) Except as
outlined in
130
CMR 406.442(B), members
enrolled in the Controlled Substance Management Program may obtain prescribed
drugs only from the member's primary pharmacy as designated by the MassHealth
agency, and only the member's primary pharmacy may receive payment from the
MassHealth agency. Members who are enrolled in this program will be identified
by the Eligibility Verification System (EVS) as participants in the Controlled
Substance Management Program.
(2)
The MassHealth agency authorizes a pharmacy other than the primary pharmacy to
dispense a nonrefillable supply of a drug to a restricted member when the
pharmacist has determined that the member's health or safety would be
jeopardized without immediate access to that drug or if the prescription is for
family planning.
(D)
Responsibilities of Primary Pharmacy. The primary
pharmacy must monitor the prescription utilization pattern of each member, and
must exercise sound professional judgment when dispensing all prescription
drugs. When the pharmacist reasonably believes that the member is presenting a
prescription that is inappropriate for his or her medical condition, the
pharmacist must contact the prescriber to verify the authenticity and accuracy
of the prescription presented. Primary pharmacies that are found on review to
be dispensing drugs in a manner that is inconsistent with professional
standards may be subject to administrative action by the MassHealth agency,
including the recovery of payments and the imposition of sanctions, in
accordance with 130 CMR 450.000: Administrative and Billing
Regulations.
(E)
Change in Primary Pharmacy and Member Status.
(1) The member may ask MassHealth to change
the member's primary pharmacy designation only once per calendar year, unless
the member can demonstrate that the designated primary pharmacy is unable to
address the member's pharmacy needs due to a change in
(a) the member's residence;
(b) the member's medical condition;
or
(c) the primary pharmacy's
business practices.
(2)
The MassHealth agency may disenroll or transfer a member from a primary
pharmacy if the pharmacy requests the change.
(3) The MassHealth agency periodically
reviews the member's drug utilization on its own initiative, or upon the
member's request, but no earlier than 12 months after the date on which the
MassHealth agency enrolled the member in the Controlled Substance Management
Program. If, after such review, the MassHealth agency determines that the
member has not used excessive quantities of prescribed drugs for at least that
12-month period, the MassHealth agency will disenroll the member from the
Controlled Substance Management Program and the member will no longer be
subject to the restrictions of that program. However, the MassHealth agency may
reenroll a member in that program at any time in accordance with the provisions
of 130 CMR
406.442(B).
