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MassHealth Accountable Care Partnership Plans and Managed Care Organizations Pharmacy Information

  • Certain MassHealth Outpatient Physician Administered Drugs to be Paid by Fee Schedule

    Information provided in the Certain MassHealth Outpatient Physician Administered Drugs to be Paid by Fee Schedule document does not apply to Managed Care Organizations (MCOs).

  • Medical Benefit

    Please see the links below for a description of Medical Benefit policies related to Accountable Care Partnership Plans (ACPPs) and MCOs, including a list of medications restricted to medical billing only. Medical Benefit drugs may be an exception to the unified pharmacy policy; please refer to respective MassHealth ACPPs and MCOs for prior authorization (PA) status and criteria, if applicable.

    Please see the links below for additional information.

     
  • Non-Rebate Drugs and Biologics

    Rebate status is subject to change. ACPPs and MCOs will follow the non-rebate drugs and biologics criteria as noted on the MassHealth Drug List (MHDL); however, timelines for implementing updates between MHDL updates may differ from that of Primary Care Clinician (PCC) plans, Fee for Service (FFS), or Primary Care Accountable Care Organizations (PCACOs).

     

  • Opioids and Analgesics       See Table 8

    Opioids and Analgesics that require PA are currently listed with the Opioid and Analgesics therapeutic class table 8 on the MHDL.

    MCOs may have different high dose thresholds and quantity limits.

    Please see the links below for more information:

     
  • Specialty Drugs and Specialty Pharmacy Networks

    Please see the links below for additional resources from ACPPs and MCOs related to Specialty Pharmacy policies, including any pharmacy network restrictions and specialty drug lists. MCOs must allow MassHealth members to fill specialty drugs outside of the in-network pharmacy if access to the medication is needed in less than 24 hours and/or the member is receiving a first fill of the medication, defined as no history of paid pharmacy claims for the agent within the most recent 180 days.

    Please see the links below for additional information.

     
  • Under Review Medications

    Please see the links below for additional resources from ACPPs and MCOs related to under review medications.

Last updated 04/01/24
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