• Editor: Vic Vangel • Contributors: Chris Burke, Gary Gilmore, Paul Jeffrey, James Monahan •
Medicare Part D Prescription Drug 
Coverage Update
We previously informed pharmacists that the 
legislatively mandated override allowing MassHealth 
to pay for a one-time 30-day supply of medication not 
covered by the member’s prescription plan would end 
on June 30, 2006. The use of this one-time override 
will continue until further notice.
Suboxone
MassHealth is taking steps to ensure that MassHealth 
members are receiving prescriptions for Suboxone  
only from prescribers who are certified to prescribe 
Suboxone.  These prescribers have received a DEA 
number that begins with the letter “X.”  We have 
created a file of these prescribers based on 
information received from the Substance Abuse and 
Mental Health Services Administration (SAMHSA) 
Buprenorphine Physician Locator Web site.  This site 
does not list all certified prescribers of Suboxone, only 
prescribers who wish to be listed.  If a pharmacy 
receives a denial on a claim with a message “25- 
Invalid Suboxone Prescriber,” the pharmacy may fax 
proof of prescriber certification to ACS at 617-423-
9846.  The prescriber’s “X” DEA number will then be 
added to the Suboxone prescriber file.  Only claims for 
Suboxone will be accepted with this unique DEA 
number beginning with an “X.”  Claims for drugs other 
than Suboxone will be denied with a message “70-
Drug Not covered for prescriber” when submitted 
with the Suboxone DEA number.  Other drugs will pay 
using the prescriber’s regular DEA number.

Claims Adjudication — “Automatic” Prior 
Authorization
You may wonder why you receive a paid response 
more often when you submit a claim for a drug that 
would normally require prior authorization (PA).  For 
example, the drug Topamax (or any other 
anticonvulsant requiring PA on the MassHealth Drug 
List), requires PA for members over 18 years old, but 
will pay without PA under certain conditions.  
MassHealth is implementing an automated solution 
that uses diagnosis codes from medical claims in the 
pharmacy claims adjudication process.  If the system 
recognizes the patient has a diagnosis code for a 
seizure disorder in their medical billing record, 
MassHealth will pay the pharmacy claim without 
additional PA.  In the past, for anticonvulsants, the 
prescriber submitted a PA form providing the seizure 
disorder diagnosis; now, with this new process in 
place, we hope to avoid that step in many cases.  One 
limitation in this process is the lag-time before a 
medical diagnosis code is displayed in the pharmacy 
system.  If a member has a newly diagnosed seizure 
disorder, MassHealth may deny a claim for Topamax 
because the POPS (Pharmacy Online Processing 
System) has not received the diagnosis data yet. In 
this circumstance a prescriber would need to request 
PA.  The MassHealth database contains member drug 
and diagnosis information exclusive to MassHealth 
and no other health plans.  This article serves as a 
reminder to submit all claims through POPS even if 
you believe the drug requires PA.  As we systemically 
roll out additional “automatic” PA rules by therapeutic 
class, we hope to greatly reduce the number of drugs 
for which prescribers will have to request PA.

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