Cash Payments

(A) No pharmacy provider may solicit, charge, receive, or accept any money, gift, or other consideration (including cash payments) from a member, or from any other person on behalf of the member, for any drug for which payment is available under MassHealth in accordance with 130 CMR 450.203: Payment in Full, and nothing in this Section 406.424 will relieve pharmacy providers of their obligations under 130 CMR 450.203. Payment is considered to be available under MassHealth even if a drug is subject to a quantity limit, dose limit, or prior authorization requirement, or prospective drug utilization review (PRO-DUR) edit, unless the prescriber has made diligent efforts to secure prior authorization or the pharmacy or prescriber has sought a PRO-DUR certification as applicable, and the MassHealth agency has denied prior authorization for the drug as not medically necessary or denied PRO-DUR certification. (B) On the date of service and prior to accepting any money, gift, or other consideration (including cash payments) from a member, or from any other person on behalf of the member, for any Schedule II-V drug (or other drug designated for reporting to the Department of Public Health’s Prescription Monitoring Program, 105 CMR 700.012(A): Pharmacy Reporting Requirements) listed on the MassHealth Drug List for which payment is not available under MassHealth, a pharmacy must (1) verify that payment is not available from MassHealth in at least one of the following ways: (a) request and obtain verification from the MassHealth agency Drug Utilization Review (DUR) Program that payment is not available under MassHealth; or (b) request and obtain verification from the prescriber certifying that: 1. the prescriber made diligent efforts to obtain prior authorization for the drug from the MassHealth agency; and 2. the prescriber’s prior authorization request was denied by the MassHealth agency as not medically necessary; or (c) verify that the drug is excluded from MassHealth coverage under 130 CMR 406.413(B); (2) verify that the member is not enrolled in the Controlled Substances Management Program (CMSP) described in 130 CMR 406.442 by utilizing the Eligibility Verification System (EVS); (3) use the Massachusetts Prescription Awareness Tool (MassPAT) to run a patient search on the member; and (4) document compliance with the requirements outlined in 130 CMR 406.424(B)(1) through (3). (C) A pharmacy that accepts any money, gift, or other consideration (including cash payments) from a member, or from any other person on behalf of the member, under 130 CMR 406.424(B) must thereafter monitor the prescription utilization pattern of the member at the pharmacy and maintain documentation of such pattern in a readily accessible form. In the event the member’s utilization pattern would indicate overutilization or improper utilization of prescribed drugs to a pharmacist exercising sound professional judgment, the pharmacy must refer the member to the MassHealth agency for potential enrollment in the CSMP. (D) A pharmacy may not solicit, charge, receive, or accept any money, gift, or other consideration (including cash payments) from a member enrolled in the CSMP, or from any other person on behalf of the member, for any drug for which payment is not available under MassHealth unless (1) the pharmacy is the member’s primary pharmacy as designated by the MassHealth agency; (2) the pharmacy has satisfied the requirements set forth in both 130 CMR 406.424(B)(1) and 130 CMR 406.424(B)(3); (3) the dispensing pharmacist certifies that in their professional judgment, the prescription is appropriate for the member’s medical condition and the member’s utilization pattern does not otherwise indicate that acceptance of any money, gift, or other consideration (including cash payment) from a member, or from any other person on behalf of the member, would be inappropriate or inconsistent with any professional standards; and (4) the pharmacy documents compliance with the requirements outlined in 130 CMR 406.424(C)(1) through (3). (E) The pharmacy must maintain the documentation described in 130 CMR 406.424(B)(4), 130 CMR 406.424(C), and 130 CMR 406.424(D)(4) in a readily accessible form, and must provide such documentation to the MassHealth agency, the Attorney General’s Medicaid Fraud Division, the State Auditor, and the United States Department of Health and Human Services on request. (F) For purposes of 130 CMR 406.424, the term “diligent efforts” means the submission, after review of all other therapeutic alternatives, of a complete and timely prior authorization request for a drug 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. A prior authorization request denied by the MassHealth agency for any other reason than as not medically necessary (e.g., missing or incomplete documentation) will not be deemed to have satisfied this requirement. The pharmacy is responsible for verifying that the prescriber undertook diligent efforts to obtain prior authorization. (G) Failure to comply with any provision of 130 CMR 406.424 may result in the imposition of sanctions against a pharmacy provider in accordance with the provisions of 130 CMR 450.000: Administrative and Billing Regulations.