MassHealth has defined "excessive quantities of prescribed drugs" as 11 or more prescriptions, including original fill and refills, of Schedule II, III, or IV controlled substances obtained from four or more prescribers or filled by four or more pharmacies. Prior to enrollment, members are notified that they have met the criteria, and are advised that they may request a letter of exemption from their Primary Care Physician (PCC) if they and their prescriber feel that their selection for the program is an error. Members will also have the opportunity to appeal MassHealth's decision before the member is actually enrolled. MassHealth strongly urges PCCs to request to see a copy of the member's Controlled Drug Prescription History before to requesting an exemption.
Enrolled members are restricted to obtaining prescribed drugs only from the provider that MassHealth designates as the member's primary pharmacy. The one exception to this is when the member cannot access the medication from their primary pharmacy (due to emergency, etc.) and a pharmacist at a different pharmacy determines that the member's health or safety would be jeopardized without immediate access to the drug. Members who are enrolled in the program will be identified by the Recipient Eligibility Verification System (REVS) as participants. All practices should ensure that the member's participation in the program is conveyed to all providers that issue prescriptions, including physicians, nurse practitioners, dentists, community health centers, and emergency departments.