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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyMassachusetts EOHHS Obesity Payment Update | OpenP…
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    CurrentMassachusetts Executive Office of Health and Human ServicesPolicy 109

    Obesity Drugs and the 340B Drug Pricing Program

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    Payment policy for specified MassHealth Managed Care Entities covering seven GLP-1 agonist drugs used in the treatment of obesity; payment is permitted only when providers use non-340B stock.

    Policy Summary
    PayerMassachusetts Executive Office of Health and Human Services
    PolicyObesity Drugs and the 340B Drug Pricing Program
    Policy CodePolicy 109
    Change TypePayment policy update
    Effective DateApril 1, 2024
    Next Review DateNot scheduled
    Key ActionUse non-340B stock for the listed drugs so the applicable Managed Care Entity may pay the claim.
    SourceLink
    POLICY UPDATE CHANGES

    Managed Care Entities must not pay for the listed drugs when providers use 340B stock.

    7Listed GLP-1 agonist drugs
    Apr 1, 2024Effective date
    4Managed Care Entity types
    MassHealth onlyMember population

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Non-340B
    Required stock source

    Payment Based on 340B Stock Status

    Payment based on 340B stock status

    For MassHealth members, evaluate payment for the listed drugs based on the provider’s source of drug stock.

    ALL of the following

    • The drug is Saxenda (liraglutide), Victoza (liraglutide), Ozempic (semaglutide), Rybelsus (semaglutide), Wegovy (semaglutide), Mounjaro (tirzepatide), or Zepbound (tirzepatide).
    • The provider uses non-340B stock.
    • Payment may be made by the applicable Managed Care Entity.

    ALL of the following

    • The drug is Saxenda (liraglutide), Victoza (liraglutide), Ozempic (semaglutide), Rybelsus (semaglutide), Wegovy (semaglutide), Mounjaro (tirzepatide), or Zepbound (tirzepatide).
    • The provider uses 340B stock.
    • Do not pay.

    Affected Drugs and Payment Requirements

    GLP-1 agonist drugs that may be used in treatment of obesitymixed
    Saxendaliraglutide
    Victozaliraglutide
    Ozempicsemaglutide
    Rybelsussemaglutide
    Wegovysemaglutide
    Mounjarotirzepatide
    Zepboundtirzepatide
    Policy Details
    Effective dateApril 1, 2024
    Stock Requirement
    Eligible stock sourceNon-340B stock only

    Provider Billing Actions

    Billing Rule

    Use non-340B stock for listed drugs

    For Saxenda (liraglutide), Victoza (liraglutide), Ozempic (semaglutide), Rybelsus (semaglutide), Wegovy (semaglutide), Mounjaro (tirzepatide), and Zepbound (tirzepatide), providers must use non-340B stock for the applicable Managed Care Entity to pay the claim.

    • Effective April 1, 2024.
    • Applies to MassHealth members and the listed drugs.
    Denial Risk

    340B stock creates payment denial risk

    Claims for the listed drugs are subject to nonpayment when the provider uses stock purchased through the 340B Drug Pricing Program. Managed Care Entities may pay for these drugs only when providers use non-340B stock.

    Key Terms

    Definitions
    340B stockDrugs purchased through the 340B Drug Pricing Program
    Definitions
    Managed Care EntitiesAccountable Care Partnership Plans, Managed Care Organizations, One Care Plans, and Senior Care Organizations
    Policy Summary
    PayerMassachusetts Executive Office of Health and Human Services
    PolicyObesity Drugs and the 340B Drug Pricing Program
    Policy CodePolicy 109
    Change TypePayment policy update
    Effective DateApril 1, 2024
    Next Review DateNot scheduled
    Key ActionUse non-340B stock for the listed drugs so the applicable Managed Care Entity may pay the claim.
    SourceLink
    On This Page
    Payment Based on 340B Stock StatusAffected Drugs and Payment RequirementsProvider Billing ActionsKey Terms
    • Listed drugs: Saxenda, Victoza, Ozempic, Rybelsus, Wegovy, Mounjaro, and Zepbound.
    • The policy applies only to MassHealth members.