Current information for pharmacist about the MassHealth Pharmacy Program
Pharmacy Facts Number 17, January 25, 2006
MassHealth Pharmacy Program

• Editor: Vic Vangel • Contributors: Chris Burke, Gary Gilmore, Paul Jeffrey, James Monahan •

Medicare Part-D Prescription Drug Coverage Update 

We would like to thank all pharmacies in the 
Commonwealth for providing a valuable service to our 
dually eligible members in processing their prescriptions.  
The transition to the Medicare Part-D plans has not been 
easy for anyone involved, and we applaud your efforts.

As you know, MassHealth has been accepting and paying 
for claims for all dually-eligible members without 
requiring evidence of Part-D coverage since emergency 
procedures were enacted on 1/7/2006.  Now we are making 
another change in claims adjudication for our dually 
eligible members, effective Thursday 1/26/2006 at 1:00 A.M.

If MassHealth receives a claim as the primary payer for a 
dually eligible member for a Part D covered drug, 
MassHealth will deny the claim.  (The Part-D excluded 
drugs, such as benzodiazepines, will pay if otherwise 
valid and available to MassHealth members).  The POPS 
system will display the message “AE – QMB Bill Medicare” 
to indicate that the member is dually eligible, and that 
the pharmacist must attempt to bill a Part-D plan.  We 
still expect that the pharmacy will use the E1 query to 
determine what Part D program a MassHealth member is 
enrolled in.  If the pharmacy cannot ascertain Part-D 
eligibility information for the member, the denial can be 
overridden by placing a “2” in the Eligibility 
Clarification Code field (NCPDP field 309-C) and 
demonstrating that the claim was sent to a Part-D plan.  
Though the claim will not deny because of Medicare-D 
coverage, it will still be subject to all of MassHealth’s 
other billing procedures and requirements.  The use of 
this Eligibility Clarification Code is a temporary 
emergency measure.  In the future, the use of this code 
will no longer override a denied claim.

In Pharmacy Facts #15, MassHealth described 
procedures for sending a claim to reduce a dually eligible 
member’s co-pay from the $2.00 and $5.00 level 
(as determined by the Part-D plan) to the standard 
MassHealth co-pay levels of $1.00 and $3.00.  
Pharmacies should use Other Coverage Code 8 when 
billing MassHealth for this co-pay.  As of Thursday 
1/26/2006 pharmacies may also submit “co-pay wrap” 
claims to MassHealth using Other Coverage Codes 2 
or 4.  The pharmacy must insert the amount of the co-pay 
required by the Part-D plan in the Patient Paid Amount 
field (NCPDP field 433-DX).  The maximum amount allowed 
in the field is $5.00, which is the highest co-pay a 
dually eligible member would be responsible for 
under Part-D.  Contact the Part-D plan if you are 
prompted to request a copayment greater than $5.00.

If a Part-D plan denies a claim because the drug is not 
on its formulary, the pharmacy may submit the claim to 
MassHealth using Other Coverage Code 3, along with the 
appropriate reject code.  The claim will still be subject 
to all of MassHealth’s other billing procedures and requirements.

Under the emergency procedures enacted on January 7, 
2006, MassHealth will continue to be the payer of last 
resort for the dually eligible member who experiences 
difficulty having a claim paid by a Medicare Part D 
prescription drug plan.  The procedures outlined above 
provide pharmacists with the information needed to allow 
these members to have an appropriately written 
prescription filled at the point of sale.

Please direct any questions or comments 
(or to be taken off of this fax distribution) to  
Victor Moquin of ACS at 617-423-9830.