130 CMR, § 433.447

Current through Register 1533, October 25, 2024

Section 433.447 - Drugs Administered in the Office (Provider-administered Drugs)

(A) Drugs and biologicals dispensed in the office are payable, subject to the exclusions and service limitations at 130 CMR 433.404, 433.406, and 130 CMR 406.413(B): Drug Exclusions and (C): Service Limitations.

(B) The MassHealth agency does not pay a provider separately for drugs that are considered routine and integral to the delivery of a provider's professional services in the course of diagnosis or treatment. Such drugs are commonly provided without charge or are included in the provider's fee for the service.

(C) The MassHealth agency does not pay separately for any oral drugs dispensed in the office for which the provider has not requested and received prior authorization from the MassHealth agency, with the exception of oral vaccines and oral radiopharmaceuticals, which do not require prior authorization.

(D) Claims for drugs and biologicals that are listed in Subchapter 6 of the Physician Manual must include the name of the drug or biological, strength, dosage, and number of HCPCS units dispensed, NDC code, NDC units and NDC unit of measurement. In addition, for drugs and/or biologicals that are listed as requiring individual consideration in Subchapter 6 of the Physician Manual, a copy of the invoice showing the actual acquisition cost must be attached to the claim. Claims without this information are denied.

(E) The MassHealth agency pays only for prescription drugs that are approved by the U.S. Food and Drug Administration and manufactured by companies that have signed rebate agreements with the U.S. Secretary of Health and Human Services pursuant to 42 U.S.C. 1396r-8. Payment is calculated in accordance with 101 CMR 331.00: Prescribed Drugs.

(F) The MassHealth agency does not pay for a biological if the Massachusetts Department of Public Health distributes the biological free of charge.