www.mass.gov/masshealth/pharmacy 

Number 52 

July 21, 2009 

Page 1 of 2 

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

Proposed Regulation Changes - Payment 
Methodology 

The Division of Health Care Finance and Policy will 
hold a public hearing on Tuesday, July 28, 2009 at 
10:00 A.M. at the Division, 2 Boylston Street, Boston, 
MA, about proposed amendments to: 

114.3 CMR 31.00: Prescribed Drugs 

The proposed amendments, effective August 1, 2009, 
alter the usual and customary charge to ensure that 
payment for MassHealth does not exceed prices that a 
pharmacist has agreed to accept from any other 
payer. 

The amendment also redefines how MassHealth will 
reimburse pharmacies for blood clotting factors by 
including the Medicare B rate as follows 

Payment for Blood Clotting Factor shall not exceed the 
lowest of: 

 

(a) the federal upper limit of the drug, if any, plus 

 the appropriate dispensing fee as listed in 114.3 

 CMR 31.06; 

(b) the Massachusetts upper limit of the drug, if any, 

 plus the appropriate dispensing fee as listed in 

 114.3 CMR 31.06; 

(c) the estimated acquisition cost, plus the 

 appropriate dispensing fee as listed in 114.3 

 CMR 31.06; 

(d) the Medicare Part B rate; or 

(e) the usual and customary charge. 

Reminder About Claims Processing When 
MassHealth is Secondary Insurer 

When a pharmacy is not a participating provider for a 
MassHealth member’s primary insurance or the 
pharmacy receives a message from the primary 
insurer that a product is covered only at certain 
network pharmacies, the pharmacy cannot 
appropriately bill MassHealth as the primary payer 
using Other Coverage Code 3. In these instances, the 
pharmacy needs to instruct the member that they need 
to use a participating pharmacy of the primary insurer. 

MHDL Updates 

1. Additions 
 a. The following newly marketed drugs will be 
added to the MassHealth Drug List effective 
August 3, 2009. 

 Acanya (clindamycin/benzoyl peroxide) – PA 

 Aplenzin (bupropion extended-release) – PA 

 Apriso (mesalamine extended-release) 

 degarelix – PA 

 Exforge HCT 

 (amlodipine/valsartan/hydrochlorothiazide) 
– PA 

 Gelnique (oxybutynin gel) – PA 

 Kapidex (dexlansoprazole) – PA 

 Lamictal ODT (lamotrigine, orally 

 disintegrating tablet) – PA 

Lamictal ODT Start Kit (lamotrigine, orally 

 disintegrating tablet) – PA 

 LoSeasonique (ethinyl 

 estradiol/levonorgestrel) 

Naprelan CR 750 mg (naproxen controlled- 

 release) – PA 

Prilosec (omeprazole suspension) – PA 

Rapaflo (silodosin) – PA 

Ryzolt (tramadol extended-release) – PA 

Toviaz 4 mg (fesoterodine) – PA > 30 

 units/month 

Toviaz 8 mg (fesoterodine) 

Uloric (febuxostat) – PA 

 Vectical (calcitrol ointment) – PA 

 Vimpat injection (lacosamide) 

 Vimpat tablet (lacosamide) – PA 

b. The following drugs will be added to the 
MassHealth Drug List effective August 3, 
2009. 

 Carmol HC (hydrocortisone/urea) 

 U-Cort (hydrocortisone/urea) 

2. Change in Prior-Authorization Status 
a. The PA requirement for Risperdal Consta is 
changing. The following PA requirement is 
effective August 17, 2009. 

 Risperdal Consta (risperidone injection) – PA 

 >2 units (2 syringes)/month 

MHDL Updates (cont.) 

b. The PA requirements for the 5-HT3 Receptor 
Antagonists are changing. The following PA 
requirements are effective August 17, 2009. 
Please see Table 27 of the MassHealth Drug 
List for a complete list of the PA requirements 
for the 5-HT3 Receptor Antagonists. 

 Anzemet (dolasetron) tablet – PA 

 granisetron tablet – PA 

 Kytril 2 mg/10 ml (granisetron) solution – PA 

c. The following drugs will require prior 

authorization effective August 17, 2009. 

  Detrol LA 2 mg (tolterodine extended-release) – 
PA > 30 units/month 

 DexPak (dexamethasone) – PA 

 Enablex 7.5 mg (darifenacin) – PA > 30 

 units/month 

 Nalfon 200 mg (fenoprofen) – PA 

 Naprelan CR 375 mg, 500 mg (naproxen 

 controlled-release) – PA 

 naproxen controlled-release – PA 

 VESIcare 5 mg (solifenacin) – PA > 30 

 units/month 

 d. The following drugs will require prior 

authorization effective August 17, 2009. 

buprenorphine powder – PA 

codeine powder – PA 

fentanyl powder – PA 

hydrocodone powder – PA 

methylphenidate powder – PA 

propoxyphene powder – PA 

sufentanil powder – PA 

  e. The PA requirement for Alinia suspension is 
changing. The following PA requirement is 
effective August 17, 2009. 

Alinia suspension (nitazoxanide) – PA 

3. Deletions 

a. The following drugs have been removed from 
the MassHealth Drug List. There are no 
products containing urea as the sole active 
ingredient that are approved by the FDA. 


Carmol (urea) 

Kerol (urea) 

Umecta (urea) 

urea 
b. The following drug has been removed from the 
MassHealth Drug List because it has been 
withdrawn from the market. 

Raptiva (efalizumab) 

c. The following drug has been removed from the 
MassHealth Drug List. MassHealth does not 
pay for drug products (including identical, 
similar, or related drug products) that the U.S. 
Food and Drug Administration has proposed, in 
a Notice of Opportunity for Hearing (NOOH) to 
withdraw from the market because they lack 
substantial evidence of effectiveness for all 
labeled indications. 

 Vanoxide-HC (benzoyl 

 peroxide/hydrocortisone) 

 4. Corrections 

The following drugs have been added to the 
MassHealth Drug List. They were omitted in error. 
These additions do not reflect any changes in 
MassHealth policy. 

Amnesteem (isotretinoin) – PA > 21 years 

Benzac W (benzoyl peroxide) – PA 

Claravis (isotretinoin) – PA > 21 years 

Ery Pad (erythromycin) – PA 

Sotret (isotretinoin) – PA > 21 years 

Testopel Pellet (testosterone) 

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

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Pharmacy Facts, Number 52