Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111
www.mass.gov/dma	
	MassHealth
	Dental Bulletin 29
	June 2003

	TO:	All Dental Providers Participating in MassHealth

	FROM:	Douglas S. Brown, Acting Commissioner

	RE:	Controlled Substances Management Program

Background 	Over the next few months, the Division will begin the process of enrolling certain MassHealth members into the Controlled Substances Management Program.  The provisions of the Program are detailed within the MassHealth pharmacy regulations at 130 CMR 406.442.  This Program is designed to enhance coordination among caregivers and pharmacies to deter members from obtaining controlled substances at a frequency or amount that is not medically necessary.

Notification of 	The Division will notify a MassHealth member that he or she has met the
Selection for Enrollment	criteria for the Program when the Division determines that the member 
into the Program	has obtained 11 or more prescriptions, including refills, for controlled substances from four or more prescribers and/or from four or more pharmacies within a three-month period. 

The initial notice to the member will include a printout that lists the member’s claims for controlled substances for the period under review.  The member will have the opportunity to ask his or her primary care clinician (PCC) to write to MassHealth’s Drug Utilization Review (DUR) Program if the PCC believes that the member should not participate in the Program.  Members will also have the opportunity to appeal the Division’s decision before the member is actually enrolled.

How the Program Works	The Program restricts enrolled members to one designated primary 
	pharmacy for all prescriptions except emergencies.  The member and the member’s PCC and primary pharmacy are notified of the member’s enrollment into the Program.  When an enrolled member presents his or her MassHealth card to a MassHealth provider, the Recipient Eligibility Verification System (REVS), or for pharmacies other than the primary 

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How the Program works 	pharmacy, the Pharmacy On-line Processing System (POPS), will alert 
(cont.)	the provider that the member is participating in the Program.  All providers that issue prescriptions, including physicians, nurse practitioners, dentists, community health centers, and emergency departments, should ensure that the information about a member’s participation in the Program is conveyed to the medical staff who make treatment decisions for the member.  

Primary Care Clinician	If a member asks you to write a letter requesting an exemption from 
Information 	enrollment into the Program, please ask the member to see a copy of the claims history of controlled substances that was sent with the member’s notice.  If you decide to request an exemption, the letter must be written on your letterhead stationery, contain an original signature, and be received within three weeks of the date of the member’s letter.   Only the member’s primary care clinician should write such a letter of exemption.

	Mail or fax the letter to the DUR Program at:

	MassHealth Drug Utilization Review Program 
P.O. Box 2586
Worcester, MA  01613-2586

1-877-208-7428 (fax)

Pharmacy Information	Primary Pharmacy 

	The Division will notify a pharmacy when it has been selected as the primary pharmacy for a member enrolled in the Program.  The notice will include the name of the member and the member’s PCC.  The primary pharmacy should add this information to the member’s automated client file.  

	Other Pharmacy

	If a member who is enrolled in the Program presents a pharmacy other than the member’s primary pharmacy with a prescription, the pharmacy will receive an error message from POPS stating that the member is restricted to another pharmacy.  If the pharmacist from the non-primary pharmacy determines that the member’s health or safety would be jeopardized without immediate access to that drug, the pharmacist may contact the DUR Program at 1-800-745-7318.  Payment is still subject to all other conditions of payment under MassHealth.

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MCO Programs	The managed care organizations (MCOs) that contract with the Division to provide health care to certain MassHealth members have or are developing similar programs.  Contact the member’s individual health plan for details.

Members’ Questions	The MassHealth Customer Service Center is available to respond to member questions.  Members may call 1-800-841-2900 (TTY:  1‑800‑497‑4648 for people with partial or total hearing loss).  

Questions	If you have questions about the Program, you may contact the DUR Program at 1-800-745-7318.