Prior Authorization

(A) Prescribers must obtain prior authorization from the MassHealth agency for drugs identified by MassHealth in accordance with 130 CMR 450.303: Prior Authorization. If the limitations on covered drugs specified in 130 CMR 406.412(A) and 406.413(A) and (C) would result in inadequate treatment for a diagnosed medical condition, the prescriber may submit a written request, including written documentation of medical necessity, to the MassHealth agency for prior authorization for an otherwise noncovered drug. (B) All prior authorization requests must be submitted in accordance with 130 CMR 450.303: Prior Authorization. and the instructions for requesting prior authorization in the Pharmacy Online Processing System (POPS) billing guide, the MassHealth Drug List, and any other applicable guidance. The MassHealth agency will notify the requesting provider and the member, in writing, of its decision. (C) The MassHealth agency will authorize at least a 72-hour emergency supply of a prescription drug to the extent required by federal law. (See 42 U.S.C. 1396r-8(d)(5).) The MassHealth agency acts on requests for prior authorization for a drug within a time period consistent with federal regulations. (D) Prior authorization does not waive any other prerequisites to payment such as, but not limited to, member eligibility or requirements of other health insurers. (E) The MassHealth Drug List specifies the drugs that are payable under MassHealth and designates which drugs require prior authorization. Any drug that does not appear on the MassHealth Drug List requires prior authorization. The MassHealth agency evaluates the prior authorization status of drugs on an ongoing basis, and updates the MassHealth Drug List accordingly. (F) If the pharmacy does not dispense a drug or non-drug product because the prescriber did not submit a request for prior authorization, the pharmacy must take reasonable steps to notify both the patient and prescriber of the need for prior authorization, and make a contemporaneous record of having done so. (G) The MassHealth agency allows exceptions to its step therapy protocol consistent with M.G.L. c.118E, § 51A. The MassHealth Drug List details the specific process for members or their prescriber seeking an exception to step therapy. (1) The MassHealth agency will grant or deny a request for an exception to the step therapy protocol or a request to appeal a denial of an exception not more than three business days after the receipt of all necessary information to establish the medical necessity of the prescribed treatment. If additional delay would result in significant risk to the enrollee's health or well-being, then this three-business day period will be reduced to 24 hours after the receipt of all necessary information to establish the medical necessity of the prescribed treatment. (2) For purposes of 130 CMR 406.422(G)(1) above, an appeal of a denial of a step therapy exception will occur through informal consultation with a clinical pharmacist with the MassHealth program or its utilization review organization. (3) Nothing in this section shall limit a member’s right to a fair hearing consistent with the timing and requirements under 130 CMR 610.000: MassHealth: Fair Hearing Rules. (4) For purposes of granting exceptions to step therapy consistent with M.G.L. c. 118E, § 51A(c)(1)(iv)(a), MassHealth is not required to consider samples provided to members absent a prescription to be a “prescription drug prescribed by the health care provider” or otherwise sufficient to establish stability. (5) Requests for exceptions to step therapy require such documentation as MassHealth requires to establish the medical necessity of the treatment or otherwise specifies on the MassHealth Drug List.