Prescription Requirements

(A) Legal Prescription Requirements. The MassHealth agency pays for prescription drugs, over- the-counter drugs, and items on the Non-drug Product List only if the pharmacy has in its possession a prescription that meets all requirements for a legal prescription under all applicable federal and state laws and regulations. Each prescription for drugs in Schedules II through V must contain the prescriber’s unique DEA number. For Schedule VI drugs, if the prescriber has no DEA registration number, the prescriber’s Massachusetts Controlled Substance Registration number must appear on the prescription. (B) Emergencies. When the pharmacist determines that an emergency exists, the MassHealth agency will pay the pharmacy for at least a 72-hour, nonrefillable supply of the drug in compliance with state and federal regulations. Emergency dispensing to a MassHealth member who is enrolled in the Controlled Substances Management Program (CSMP) must comply with 130 CMR 406.442(C)(2). (C) Refills. (1) The MassHealth agency pays for a maximum of 11 refills, except where federal or state law prohibits, or where the MassHealth Drug List or Pharmacy Facts or other written issuance from the MassHealth agency specifically limits the number of refills, duration of the prescription, or both. (2) The MassHealth agency pays for more than 11 refills within a 12-month period if such refills are for less than a 30-day supply and have been prescribed and dispensed in accordance with 130 CMR 406.411(D). (3) The MassHealth agency does not pay for any refill dispensed after one year from the date of the original prescription. (4) The MassHealth agency does not pay for any refill without an explicit request from a member or caregiver for each filling event. The possession by a provider of a prescription with remaining refills authorized does not in itself constitute a request to refill the prescription. (D) Quantities. (1) Days’ Supply Limitations. (a) The MassHealth agency requires that all drugs be dispensed in a 30-day supply, unless the drug is available only in a larger minimum package size, except as specified in 130 CMR 406.411(D)(1)(b) and 130 CMR 406.411(D)(2). (b) 90-day supplies. The MassHealth agency requires or allows that drugs be dispensed in a 90-day supply in the following circumstances, except as specified in 130 CMR 406.411(D)(2). 1. Required 90-day Supplies. The MassHealth agency requires certain designated generic drugs, other designated low-net-cost drugs, and drugs listed as preferred in the Brand Name Preferred section of the MassHealth Drug List to be dispensed in a 90-day supply after a trial supply is dispensed in up to a 30-day supply. Drugs subject to this requirement will be designated in the MassHealth Drug List. This requirement does not apply to drugs dispensed to members in certain long term care facilities, hospices, and group homes, or as specified by law or regulation. 2. Allowed 90-day Supplies. MassHealth allows that drugs be dispensed in up to a 90-day supply in the following circumstances. a. Drugs designated in the MassHealth Drug List as allowed to be dispensed in 90-day supplies. 4. Program Regulations b. Drugs for which the MassHealth agency is not the primary payer but for which payment is available from the MassHealth agency for any portion of the claim (including any copayment or deductible), provided that the primary payer will pay for the drug when dispensed in up to a 90-day supply. Exceptions prohibiting the dispensing of a drug in a 90-day supply set forth in 130 CMR 406.411(D)(2) do not apply if the primary payer will pay for the drug when dispensed up to a 90-day supply. (c) The MassHealth Drug List 90-day Supply Page. This page on the MassHealth Drug List describes the types of drugs that are allowed or required to be dispensed in a 90-day supply. This page also notes exclusions to the 90-day supply program which are at the discretion of the MassHealth agency. (2) Exceptions to Days’ Supply Limitations. (a) The MassHealth agency allows exceptions to the limitations described in 130 CMR 406.411(D)(1) for the following products: 1. drugs in therapeutic classes that are commonly prescribed for less than a 30-day or 90-day supply (as applicable), including but not limited to antibiotics and analgesics; 2. drugs that, in the prescriber's professional judgment, are not clinically appropriate for the member in a 30-day or 90-day supply (as applicable); 3. drugs that are new to the member, and are being prescribed for a limited trial amount, sufficient to determine if there is an allergic or adverse reaction or lack of effectiveness. The initial trial amount and the member's reaction or lack of effectiveness must be documented in the member's medical record; 4. drugs packaged in such a way that the smallest quantity that may be dispensed is larger than a 30-day or 90-day supply, as applicable (for example, inhalers, ampules, vials, eye drops, and other sealed containers not intended by the manufacturer to be opened by any person other than the end user of the product); 5. drugs in topical dosage forms that do not allow the pharmacist to accurately predict the rate of the product’s usage (for example, lotions or ointments); 6. products generally dispensed in the original manufacturer’s packaging (for example, fluoride preparations, prenatal vitamins, and over-the-counter drugs); 7. drugs designated by MassHealth as required to be dispensed in less than 30-day or 90-day supplies (as applicable) in order to limit potential fraud, waste, or abuse; 8. opioid substances in Schedule II if the patient requests less than the prescribed quantity as provided in M.G.L. c. 94, § 18(d3/4); and 9. as designated in a Pharmacy Facts, provider bulletin, or other written issuance from the MassHealth agency. (b) Drugs used for family planning may be dispensed in up to a 365-day supply. (E) Prescription-splitting. Providers must not split prescriptions by filling them for a period or quantity less than that specified by the prescriber. For example, a prescription written for a single 30-day supply may not be split into three 10-day supplies. The MassHealth agency considers prescription-splitting to be fraudulent. (See 130 CMR 450.238(B)(6).) Partial fills of prescriptions pursuant to an exception to days’ supply limitations described above in 130 CMR 406.411(D)(2)(a) are not considered prescription-splitting for purposes of 130 CMR 406.411(E). (F) Excluded, Suspended, or Terminated Clinicians. The MassHealth agency does not pay for prescriptions written by clinicians (1) who have been excluded from participation based on a notice by the U.S. Department of Health and Human Services Office of Inspector General; or (2) whom the MassHealth agency has suspended, terminated, or denied admission into its program for any other reason.