Program and Benefit Design
UMass Medical School's Center for Health Policy and Research provides program benefit and design support for the MassHealth pharmacy program. The primary objective is to ensure MassHealth subscribers receive pharmacy benefits for medications that are medically necessary, medically appropriate, cost-effective, and in compliance with federal and state Medicaid regulations.
This is primarily accomplished through two major undertakings:
- The MassHealth Drug List
- The Pharmacy Online Processing System
The MassHealth Drug List
First developed in 2002, the MassHealth Drug List identifies preferred drugs for pre-defined medical treatments based on clinical efficacy, safety, and cost effectiveness. For example, loratadine, a generic over-the-counter antihistamine, is approved (i.e., readily available) for allergy treatment, whereas Allegra, a brand-name prescription, would require clinical review.
The MassHealth Drug List includes more than 3,000 prescription medications. It is updated regularly as new therapeutic classes are evaluated and as new drugs come to market. The list is an available online link and provides detailed, up-to-date information about MassHealth Pharmacy Program policies. MassHealth is a leader among Medicaid programs for its use of generic drugs.
The Pharmacy Online Processing System (POPS)
POPS is a robust software system that provides real-time submission and approval of MassHealth pharmacy claims, as the prescription is entered at the subscriber’s local pharmacy. The system checks for up to 350 different conditions, such as:
- Member eligibility,
- MassHealth Drug List inclusion,
- Prescription quantity limits,
- Prescription refill eligibility,
- Prescription drug interactions, and more.
POPS also fulfills other pharmacy program needs, supporting the federal drug rebate program and data analysis, as well as invoice generation, payment reconciliation, and dispute resolution.