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Controlled Substances Management Program: Questions and Answers for Prescribers

CSMP Q&A for Prescribers

Questions and Answers

Why or how was my patient picked to be in this program?

Your patient met the criteria to be placed into the program. MassHealth has reviewed paid pharmacy claims data for this patient, and has found that your patient is receiving high numbers of prescriptions for controlled substances. Our pharmacy claims data show that your patient received 11 or more prescriptions and refills for controlled substances during a 3-month period. Additionally, these prescriptions were written by 4 or more prescribers and/or filled by 4 or more pharmacies.

I believe that the pattern of obtaining controlled substances was medically necessary. What do I need to do so that the member is not put into the program?

The member's primary care clinician may send a letter demonstrating the medication need for the member's use of controlled substances. The letter should be written on the provider's letterhead stationery, contain an original signature, and be received within 3 weeks of the date of the member's letter.

Mail or fax the letter to:

MassHealth Drug Utilization Review Program
P.O. Box 2586
Worcester, MA 01613-2586
Fax: 1-877-208-7428

If the member is exempted from the program how long will the member be exempted for?

MassHealth does not have a set exemption period, but will review the member's paid claims data in the future to determine if he or she still meets the criteria. If the member meets the criteria in the future, MassHealth may again notify the member that he or she will be part of the program.

When does the program start?

Approximately 34 days from the date of the letter informing the member that he or she will be enrolled in the program.

This is the second letter that we send to members about enrollment into the program. The first letter informs the member that he or she satisfies the program's criteria, and the second letter is a formal notice of MassHealth's intent to enroll the member into the program.

How does the program work?

Your patient will be restricted to one primary pharmacy. His or her primary pharmacy will be given the name of the member's primary care clinician (PCC). In addition, whenever the member's MassHealth card is checked through the MassHealth Recipient Eligibility Verification System (REVS), the system will identify the member as a participant in the program.

How will the primary pharmacy be picked?

In general, MassHealth will select the last pharmacy that the member used, based on paid claims history, as the primary pharmacy. The member may pick a different primary pharmacy by sending a completed Pharmacy Change Form, which is enclosed in their notification package, to:

MassHealth Drug Utilization Review Program
P.O. Box 2586
Worcester, MA 01613-2586
Fax: 1-877-208-7428

What are the responsibilities of a MassHealth member's primary pharmacy?

MassHealth sends a letter to the primary pharmacy informing them of the member's enrollment and the member's primary care clinician. The primary pharmacy must make note of this information within their automated client file. They should treat this member as they would any other MassHealth member. If they want to terminate the member, they must inform MassHealth of their intention to do so, the reason, and the effective date of such termination.

MassHealth will send a notice to the member stating the reason for the transfer, as well as the name, address, and phone number of the new primary pharmacy.

How long will a member be enrolled in the program?

MassHealth will periodically review the member's drug utilization on its own initiative, or upon the member's request, but no earlier than 12 months after the date on which MassHealth enrolled the member in the Controlled Substance Management Program. If, after such review, MassHealth determines that the member no longer meets the criteria, MassHealth will disenroll the member from the Controlled Substances Management Program.

Members requesting such a review must send a written request to:

MassHealth Drug Utilization Review Program
P.O. Box 2586
Worcester, MA 01613-2586
Fax: 1-877-208-7428

The letter from MassHealth identifies a member for enrollment in the Controlled Substances Management Program. I am listed as the member's primary care clinician, but I do not (currently) have this member as a patient. What should I do?

Call MassHealth Customer Service at 1-800-841-2900.

How should a pharmacist approach a MassHealth member who is restricted to a different pharmacy and presents with a prescription for a drug that the pharmacist would like to fill because he or she thinks that the member's health or safety would be jeopardized without immediate access to the drug?

The pharmacist should call the Drug Utilization Review (DUR) program at 1-800-745-7318 and tell them that they are aware that the member is enrolled in the Controlled Substances Management Program and is restricted to another pharmacy. The pharmacist should also tell them that they have determined that the member's health or safety would be jeopardized without immediate access to the prescribed drug. Payment is still subject to all other conditions of payment under MassHealth.