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

NewMMIS Update 

The NewMMIS Project and Executive Team recently 
reviewed the status of the project, resulting in the 
decision to delay implementation. You will be informed of 
the new implementation date as soon as it is confirmed. 
Please refer to the MassHealth NewMMIS Web page at 
www.mass.gov/masshealth/newmmis for updated 
timelines and reference materials. 

Please remember that MassHealth members are 
receiving new member ID cards and pharmacy providers 
may use these new member ID numbers on claims 
processed through the Pharmacy Online Processing 
System (POPS). Claims submitted to the legacy MMIS, 
such as those for DME services, require the legacy 
member ID (10 digits). 

Medicare Part-D Prescription Drug 
Coverage Update 

MassHealth continues to provide assistance with 
Medicare Part D prescription drug plan copayments to 
ensure that the member does not pay a copayment that 
is greater than the standard MassHealth copayment. 
Currently the maximum amount that a Part D plan is 
permitted to charge a dually eligible member is $5.60. 
Effective January 1, 2009, this maximum amount will 
increase to $6.00. Beginning Monday, December 22, 
POPS will deny a claim for a Part D copayment that is 
greater than these allowed maximums for dually eligible 
members. The pharmacy will receive a denial that states 
“Submitted Med-D copay exceeds MassHealth’s 
maximum limit.” If the Part D plan assesses a copayment 
in excess of these maximum amounts, pharmacy staff 
will need to contact the Part D plan in order for the plan 
to correct the copayment amount. Part D plans are 
required to accept best available evidence (BAE) as 
proof that an individual has MassHealth and should 
therefore be charged the low-income-subsidy level 
copayments. For detailed information on what constitutes 
BAE, refer to the Centers for Medicare & Medicaid 
Services (CMS) Web site at www.cms.hhs.gov. Click first 
on the link for Medicare, then on Prescription Drug 
Coverage Contracting, in the right column. Next, click 
on the link for Best Available Evidence (BAE), and 
then on the link to the Clarified BAE Guidance memo 
(v08.04.08). 

If a Part D plan is unwilling or unable to correct the 
copayment amount at the time the prescription is filled, 
the MassHealth denial can be overridden by placing a 
“99” in the Submission Clarification field (NCPDP field 
420-DK). By using this override, the pharmacy is 
certifying that an attempt was made to contact and 
correct the copayment amount with the Part D plan. The 
use of these overrides will be closely monitored. 

Please note that dually eligible members who choose to 
receive their prescription drugs through a non-Part D plan 
(i.e. commercial insurance or “creditable coverage”), and 
have no Part D coverage, will not receive MassHealth 
assistance with drug copayments for any Part D covered 
drugs when provided by a non-Part D plan. For dually 
eligible members who have both a Part D plan and 
commercial insurance, both plans must be billed before 
sending the claim to MassHealth. MassHealth provides 
copayment assistance only if the Part D plan pays a 
portion of the claim, and the remaining balance exceeds 
the MassHealth copayment. If you are unsure of the 
correct billing order, send the claim to the Part D plan 
and you will receive an online message about the correct 
order of billing. 

Please note that some classes of drugs could be covered 
by Medicare B or by Medicare D, depending on the 
circumstances. A table explaining these coverage issues 
can be found on the pharmacy pages of the CMS Web 
site at www.cms.hhs.gov/pharmacy. Click first on the link 
for Parts B and D Information and then on Medicare 
Parts B and D Coverage Issues Table. 

 

An example of a drug class where some confusion exists 
is the immunosuppressants. Medicare Part B would be 
responsible for paying for these prescriptions if the 
member was eligible for Medicare at the time of 
transplant. Medicare Part D would assume responsibility 
for payment if the service is not Medicare Part B covered. 
If a Part D plan requires a prior authorization (PA) for an 
immunosuppressant, the pharmacy must attempt to 
obtain that PA from the Part D plan. MassHealth should 
never be the primary payer for this class of drugs for a 
dually eligible member. Other examples of drugs that 
could be covered under Part B or Part D depending on 
the circumstance, are oral anti-cancer agents, oral anti-
emetics, and erythropoietin. 



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 47 

December 18, 2008