MassHealth pharmacy co-payment changes
On October 1, 2011, MassHealth pharmacy co-payments will increase from $3 to $3.65 for most covered prescriptions and refills of brand-name, generic, and over-the-counter (OTC) prescriptions. This change applies to all MassHealth members, including Network Health Together members, age 19 and over who are not exempt from co-payments. The co-payment will remain $1 for certain covered generic and OTC medications in the following drug classes: antihyperglycemics, antihypertensives, and antihyperlipidemics. Please see our Preferred Drug List for additional information.
If a Network Health Together (MassHealth) member is unable to pay a co-payment at the time of service, the pharmacy must fill the prescription. However, the pharmacy can bill later for the co-payment.
Commonwealth Care Plan Type I co-payment changes
On October 1, 2011, Commonwealth Care Plan Type I pharmacy co-payments will increase from $3 to $3.65 for most covered prescriptions and refills of brand-name, generic, and over-the-counter (OTC) prescriptions. This change applies to all Commonwealth Care Plan Type I members, including Network Health Forward members, who are not exempt from co-payments. The co-payment will remain $1 for certain covered generic and OTC medications in the following drug classes: antihyperglycemics, antihypertensives, and antihyperlipidemics. There is no change to pharmacy co-payments for members of Commonwealth Care Plan Types II and III. Please see our Preferred Drug List for additional information.
Populations exempt from pharmacy co-payments
The following populations are exempt from pharmacy co-payments:
Network Health Together members
- American Indians and Alaskan Natives from federally recognized tribes (effective October 1, 2011)
- Members under the age of 19
- Members who were in the care of the Department of Children and Families (DCF) and whose MassHealth coverage continued after they turned 18
Network Health Together and Network Health Forward members
- Women who are pregnant or whose pregnancy ended less than 60 days prior
- Patients in nursing facilities, immediate-care facilities for the developmentally delayed, or hospitals serving patients with acute, chronic-disease, or rehabilitation needs
- Members in hospice care
- Members who have reached their pharmacy co-payment cap for the calendar year
Angiotensin II Receptor Blocker (ARB) coverage
As of July 1, 2011, Network Health extended unrestricted coverage to losartan and losartan-hydrochlorothiazide. Effective October 3, 2011, Network Health will update the ARB step-care therapy to cover Avapro and Avalide, along with Benicar, Benicar HCT, Diovan, and Diovan HCT. You must get prior authorization unless we have processed a claim for losartan or losartan-hydrochlorothiazide not more than 180 days prior to a claim for a covered brand-name ARB.
Oral contraceptive coverage
Effective October 3, 2011, Network Health will no longer cover Ortho Tri-Cyclen Lo. Your Network Health patients can continue to receive Ortho Tri-Cyclen Lo if we have paid a claim for it within the last 180 days. Network Health covers all generic oral contraceptives without restriction and with no co-payment.
Preferred pegylated interferon: Peg-Intron
Effective October 3, 2011, we are removing Pegasys from the Preferred Drug List. Peg-Intron is now the preferred pegylated interferon for the treatment of Hepatitis C. We require prior authorization for Peg-Intron. If your Network Health patient has already begun treatment with Pegasys and meets the coverage guidelines for Hepatitis C medications, your patient can continue to receive Pegasys. If your Network Health patient is starting treatment after October 3, 2011, please prescribe Peg-Intron, if appropriate.
72-hour emergency supply of drugs
To provide the best possible care for your Network Health patients, we cover an emergency supply of drugs that are on our Preferred Drug List and require prior authorization. Once per year, your Network Health patients are eligible to receive up to a 72-hour emergency supply of a specific drug and strength while you submit a prior authorization request to MedImpact. To check whether a drug requires prior authorization, please see our searchable Preferred Drug List.
Pharmacy providers must submit a claim for an emergency supply with “3” as the level of service. We do not reimburse an emergency supply if your patient is not enrolled with Network Health, the drug is not on the Preferred Drug List, or the claim is rejected as “refill too soon.” If you have any questions, please call MedImpact at 800-788-2949.