NEW MASSHEALTH PRESCRIPTION DRUG POLICY

Note: the following does NOT apply to MassHealth managed care plan members (such as Neighborhood Health Plan, Network Health, Fallon Community Health Plan)- they will follow the rules set by their specific health plans. It DOES apply, however, to mental health services through the Partnership.

Effective November 28, 2001, for all new prescriptions MassHealth now requires prior authorization for brand-name drugs where an equivalent generic alternative exists. If a generic does not exist, MassHealth will cover the brand-name drug without prior authorization. For prescriptions written before November 28 refills will still be brand-name until that prescription expires or runs out.

Under the new policy to get prior-approval the physician will need to show that there is a special medical need for a brand-name drug . The notice that MassHealth sent to members states, "Since generic drugs have the same medical ingredients as brand-name drugs and usually work the same way in your body, it is rare that there will be a special medical need for a brand-name drug." Providers will have the burden of proving that the brand-name drug is medically necessary.

MassHealth has contracted with the Drug Utilization Review Program (508-721-7171) to make clinical decisions about necessity.

If MassHealth members want to receive the brand-name drug without prior approval, MassHealth will now allow for the member to pay out of pocket.

For questions about this policy change contact the MassHealth Pharmacy Customer Service Hotline at 800-441-0323 (TTY: 800-497-4648) Monday through Friday 8 am to 8pm.

-Adapted from the Massachusetts Hospital Association's Advisory, November 23, 2001 and the MassHealth Generic Drug Member Notice, 9/01.

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