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

Medicare Part D Reminders 

For dual-eligible members enrolled in Medicare 
Part D drug plans 

MassHealth is required to pay for a one-time 72-hour 
supply if the pharmacy is unable to bill a Part D plan or 
the Wellpoint/Anthem point of sale facilitator. After an 
unsuccessful attempt to bill the member’s Part D plan 
and Wellpoint/Anthem, pharmacists should use the 
standard NCPDP other payer reject codes to override a 
denied claim when a Part D plan and/or Wellpoint will not 
pay a claim for a Part D drug. A level-of-service code of 
“03” must also be entered on the claim. 

MassHealth also provides assistance with Part D plan 
copayments. The pharmacy should collect from the 
member the copayment the member would have paid 
under MassHealth ($0 to $3) and send a claim to 
MassHealth for the remainder, using Other Coverage 
Code 2, 4, or 8. 

Note: Drugs excluded from the Medicare Part D program 
(benzodiazepines, barbiturates, and certain OTCs) are a 
regular MassHealth benefit for dual-eligible members. Bill 
MassHealth directly for these drugs and charge the usual 
MassHealth copayment. 

For dual-eligible members that have “opted out” 
of a Medicare Part D drug plan 

Members who choose to receive their drugs through a 
non-Part D plan (i.e., commercial insurance or “creditable 
coverage”) do not receive MassHealth assistance with 
drug costs or drug copayments for any Part D covered 
drugs when they are provided by a non-Part D plan. 

Note: Certain drugs excluded from the Medicare Part D 
program (benzodiazepines, barbiturates, certain OTCs) 
are a regular MassHealth benefit for dual-eligible 
members. Bill MassHealth directly for these drugs and 
charge the usual MassHealth copayment. 

Dose Consolidation — Atypical 
Antipsychotics 

As previously stated, the atypical antipsychotics will have 
quantity limits as of 10/1/07. Pharmacists will be able to 
execute most dose consolidations (e.g., a prescription for 
Zyprexa 5 mg, 2 tablets daily, converted to Zyprexa 10 mg,
1 tablet daily). Other prescriptions may require the 
prescriber to write two prescriptions (e.g.,Zyprexa 2.5 mg, 
5 tablets daily, being converted to Zyprexa 10 mg, 1 tablet 
daily, and Zyprexa 2.5 mg, 1 tablet daily). 

When a second prescription is needed to accommodate 
this dose consolidation, the MassHealth member is not 
charged a copayment for the second prescription, as long 
as both prescriptions are processed by the same 
pharmacy on the same day. MassHealth intends to 
expand this dose consolidation initiative to other drugs in 
the future. 

Prescriber DEA numbers 

MassHealth continues to adopt measures to ensure that 
the proper prescriber DEA number appears on a 
prescription claim. Currently, a delay exists between the 
time a newly licensed prescriber receives a DEA number 
and when MassHealth receives an updated list of these 
numbers from the Drug Enforcement Administration. 
There is a 90-day grace period beginning from the first 
time the Pharmacy Online Processing System (POPS) 
receives a claim with an unrecognized DEA. If, after 90 
days, POPS does not receive updated information on this 
DEA number, it will deny subsequent claims submitted 
with the unrecognized DEA number. During the 90-day 
grace period, the pharmacy will receive a message 
stating that “Prescriber ID on file but will expire at end of 
90 day grace period.” After the 90-day grace period, any 
claim submitted with the unrecognized DEA number will 
deny with NCPDP Reject Code 25 (Invalid Prescriber ID). 



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

www.mass.gov/masshealth/pharmacy 

Number 29 

August 28, 2007