Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA  02111

MassHealth
Nurse Practitioner Bulletin 9
February 2001

TO:        Nurse Practitioners Participating in MassHealth FROM:       Wendy E. Warring, Commissioner
RE:        Injectable and Infusible Drugs and Devices

Introduction
Supplying Injectable or Infusible Drugs and Devices

The purpose of this bulletin is to provide an updated list of injectable and infusible drugs and devices administered in a practitioner’s office or dispensed to a member for self-administration that require prior authorization (please refer to the attachment to this bulletin).
This bulletin also introduces options for supplying injectable and infusible
drugs administered in a practitioner’s office. To ensure appropriate
transport and dispensing of the drug or device, the pharmacy must not
dispense the injectable or infusible drug or device directly to the
MassHealth member unless the item is for self-administration. This
directive applies to all injectable and infusible drugs and devices, not just
for those that require prior authorization.
	
The Division allows two options for payment of injectable and infusible drugs and devices.
·	The MassHealth practitioner may bill for supplying these drugs and
devices in the office.
·	The MassHealth pharmacy may bill for the drugs or devices delivered
to the office of a MassHealth practitioner administering the drugs or
devices.

Prior-Authorization Instructions for Practitioner-Supplied Injectables and Infusibles

To obtain prior authorization for injectable and infusible drugs and devices that are supplied and administered in the office, practitioners must submit a request for prior authorization to the Division on the Division’s standard prior-authorization form, which may be obtained from MassHealth Forms Distribution. (The address is listed later in this bulletin.)
The Request for Prior Authorization must contain the information required in the billing instructions in Subchapter 5 of the Physician Manual. No other form, including letterhead, will be accepted for prior-authorization requests for drugs and devices dispensed and administered in the office.

MassHealth
Nurse Practitioner Bulletin 9
February 2001
Page 2

Prior-Authorization Instructions for Practitioner-Supplied Injectables and Infusibles
(cont.)

Item 3 of the prior-authorization form must contain the MassHealth provider number of the practitioner who will be administering the drug or device. Do not enter your group practice number (the seven-digit number beginning with 97.) NOTE: This instruction applies only when you are requesting prior authorization. It does not change the way in which you enter provider numbers on the claim form.
If a provider other than the one listed on the prior-authorization form will administer the drug or device, the provider must submit a new request for prior authorization with his or her own provider number and receive approval before the drug or device is administered. The provider name on the prior-authorization form must match the provider name on the claim form. Otherwise, the Division will deny the claim.
When a provider refers a member to another setting, such as a community health center, for administration of an injectable or infusible drug or device, the community health center to which the member is being referred must obtain prior authorization.

Prior-Authorization	Prior authorization for drugs or devices supplied by a MassHealth
Instructions for	pharmacy that delivers these items to a practitioner’s office or supplies
Pharmacy-Supplied	these items to a member for self-administration must be requested by the
Injectables and	prescribing practitioner.
Infusibles
The Request for Prior Authorization must contain the information required in the billing instructions in Subchapter 5 of the Physician Manual. No other form, including letterhead, will be accepted for prior-authorization requests for drugs and devices dispensed and administered in the office or supplied to a member for self-administration.
The request for prior authorization must include the name, address, and telephone number of the MassHealth pharmacy that will fill the prescription.
Drugs and	The Division does not pay separately for hydration, antiemetics, or other
Hydration	non-chemotherapy drugs when such drugs are administered in conjunction
Administered with	with the chemotherapy infusion. However, the Division pays for these
Chemotherapy	drugs and hydration when they are administered before or after the
infusion of chemotherapy.

MassHealth
Nurse Practitioner Bulletin 9
February 2001
Page 3

Address for
Prior-Authorization
Requests

Submit all prior-authorization requests for injectable and infusible drugs and devices to the following site.
University of Massachusetts Medical School DUR Program Offices 11 Midstate Drive Auburn, MA 01501
Telephone: 1-800-745-7318 Fax: 1-877-208-7428

Payment

In accordance with Division regulations at 130 CMR 433.440(C), drugs dispensed in a practitioner’s office will be paid at the practitioner’s actual acquisition cost, subject to the terms and conditions of 130 CMR 433.000 and 450.000.

Billing Procedures for Practitioner-Supplied Injectables and Infusibles

Compliance with the following directives will help ensure the proper processing of your claims.
All claims submitted for injectable and infusible drugs and devices require the name, strength, total dose administered, and the total number of units administered (such as mg and cc) to appear on claim form no. 5. If possible, list the NDC number of the drug.
Attach a copy of the current invoice showing the actual acquisition cost to the claim form. The Division will deny claims that lack the required information.
Enter the prior-authorization number in Item 23D of claim form no. 5.
Verify that the provider number of the practitioner administering the drug is identical to the provider number listed on the Division’s prior-authorization approval. Otherwise, the Division will deny the claim.
You may request payment for the administration of the drug on the same claim form. Use the appropriate service code for administration from Subchapter 6 of the Physician Manual.

Drugs No Longer
Requiring
Prior Authorization

The following drugs no longer require prior authorization.
Algucerase (Ceredase, Cerezyme) Alph-1 proteinase inhibitor (Prolastin) Dornase alpha inhalation solution (Pulmozyne) Herceptin

MassHealth
Nurse Practitioner Bulletin 9
February 2001
Page 4
Supplies of	To obtain supplies of the Request for Prior Authorization Form send or fax
Prior-Authorization	a written request to the following site.
Request Forms
MassHealth Forms Distribution P.O. Box 9101 Somerville, MA 02145
Fax: (617) 576-4087

Questions

If you have any questions about the information in this bulletin, please contact the MassHealth Provider Services Department at (617) 628-4141 or 1-800-325-5231.

Injectable or Infusible Drugs and Devices Requiring Prior Authorization
The following is a list of drugs that require prior authorization when dispensed in a prescriber’s office or supplied to a MassHealth member for self-administration. Each category includes all FDA and future approved FDA drugs.
 •	antirheumatic injectables (for example, Enbrel)
 •	botulinum toxin (for example, Botox, Mylobloc)
 •	colony stimulating factors (for example, Leukine, Neupogen)
 •	compounded medications for infusion (for example, active medication containing more than one ingredient)
 •	gonadotropin-releasing hormone analog (for example, Lupron)
 •	hyaluronic acid derivatives (for example, Hyalgan, Synvisc)
 •	immune globulin intravenous (IGIV) (for example, Sandoglobulin, Venoglobulin)
 •	injectable muscle relaxants (for example, Lioresal)
 •	monoclonal antibodies (for example, Remicade, Synagis)
 •	recombinant human erythropoetin (for example, Epogen, Procrit)
 •	recombinant human growth hormone (HGH) (for example, Geref, Humatrope)
Billing
Practitioners and community health centers are reminded that all claims submitted for drugs and devices require the name, strength, total dose administered, and total number of units administered (such as mg and cc) to appear on the necessary claim form. A copy of the current invoice showing the actual acquisition cost must be attached to the claim form.
Practitioners and community health centers must refer to Subchapter 6 of their provider manual to find the appropriate service codes when billing for injectable and infusible drugs dispensed in the office or clinic.
In addition, oral drugs dispensed in a practitioner’s office or a community health center, with the exception of oral vaccines, also require prior authorization.
Pharmacies may no longer dispense injectable or infusible drugs and devices directly to members unless the item is for self-administration.

Notice to MassHealth Members
Beginning February 15, 2001, there will be two changes to how you, your doctor, or your clinic get certain medications that your doctor then gives you by injection (a shot) or intravenously (I.V.)
1.	Your doctor will need to get prior authorization before he or she can
give you the following medications.
 •	baclofen (Lioresal);
 •	botulinum toxin (Botox; Mylobloc);
 •	hylan G-F 20 (Synvisc).
 •	leuprolide acetate (Lupron)
2.	You will no longer be able to get the following medications and others
like them from your pharmacy. Your doctor or clinic will have to get
these medications before your appointment.
 •	sodium hyaluronate (Hyalgan)
 •	Infliximab (Remicade)
 •	Immune Globulin Intravenous (Sandoglobulin, Venoglobulin,
Gammar-P, Gammagard S/D, Gamimune, Panglobulin, Iveegam, Polygam S/D)
We will also your doctor or clinic and your pharmacy about these changes before February 15, 2001.
Please call your doctor if you have any questions about this notice.