Provider Eligibility

(A) All Providers. A pharmacy must be a participant in MassHealth on the date of service in order to be eligible for payment. (B) In-state Providers. To be eligible for participation as a MassHealth provider, a pharmacy must (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: Licensure of Pharmacies, or be licensed by the Massachusetts Department of Public Health and dispensing as a pharmacy in a clinic or hospital setting in accordance with M.G.L. c. 111 and 105 CMR 722.000: Dispensing Procedures for Clinic and Hospital Pharmacies; (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. (C) Out-of-state Providers. (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 (a) is licensed by the Board of Registration in Pharmacy (or the equivalent) in the state in which the provider primarily conducts business and in accordance with applicable provisions of 247 CMR 6.00: Licensure of Pharmacies; (b) possesses a DEA registration number; (c) participates in the Medicaid program or equivalent of the state in which the provider primarily conducts business; and (d) agrees to use the MassHealth agency Pharmacy Online Processing System (POPS) in real-time mode to submit claims. (2) Limited Purpose Out-of-state Providers. (a) If a pharmaceutical manufacturer supplies a drug only to a pharmacy that is located outside of Massachusetts, and the drug is medically necessary for a MassHealth member, the MassHealth agency may enroll such a provider for the limited purpose of dispensing the drug, and may only reimburse the pharmacy for the dispensing of that drug. The provider must agree to this restriction as a condition of enrollment and meet the requirements of 130 CMR 406.404(C)(1)(a) through (d). (b) If a member is covered by other primary insurance and that carrier requires use of an out-of-state pharmacy, MassHealth may enroll that pharmacy for the purpose of submitting secondary claims only. (c) If the drug later becomes readily available within Massachusetts, the MassHealth agency may disenroll the limited purpose out-of-state pharmacy. (D) Participation in the 340B Drug Pricing Program for Outpatient Pharmacy Services. The MassHealth agency does not cover drugs billed through pharmacy point-of-sale adjudication when these drugs are acquired through the 340B Drug Pricing Program.