Injectable and Infusible Drugs and Devices
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Governs prior-authorization, billing, and supply options for injectable and infusible drugs and devices administered in physicians' offices or supplied for self-administration to MassHealth members; affects MassHealth participating physicians, pharmacies, and community health centers.
Introduces two options for payment/supply: physician may bill for office-supplied injectables/infusibles or pharmacy may bill when delivering items to the physician's office.
A list of drug categories and examples that require prior authorization when dispensed in a prescriber's office or supplied for self-administration.
The Division does not pay separately for hydration or antiemetics administered with chemotherapy infusions unless given before or after the infusion.
Specific drugs no longer require prior authorization (Algucerase, Alph-1 proteinase inhibitor, Dornase alpha, Herceptin).
Coverage and Billing Rules
Coverage and billing criteria for injectable/infusible drugs
Prior authorization is required for the listed categories of injectable and infusible drugs and devices when dispensed in a prescriber's office or supplied to a member for self-administration. Payment and billing must follow Division rules.
Drugs/categories requiring prior authorization
- Antirheumatic injectables (e.g., Enbrel).
- Botulinum toxin (e.g., Botox, Mylobloc).
- Colony stimulating factors (e.g., Leukine, Neupogen).
- Compounded medications for infusion (e.g., active medication containing more than one ingredient).
- Gonadotropin‑releasing hormone analog (e.g., Lupron).
- Hyaluronic acid derivatives (e.g., Hyalgan, Synvisc).
- Immune globulin intravenous (IGIV) (e.g., Sandoglobulin, Venoglobulin).
- Injectable muscle relaxants (e.g., Lioresal).
- Monoclonal antibodies (e.g., Remicade, Synagis).
- Recombinant human erythropoetin (e.g., Epogen, Procrit).
- Recombinant human growth hormone (HGH) (e.g., Geref, Humatrope).
Drug Identification and Claim Details
| NDC (if possible) | Providers should list the NDC number of the drug on the claim if possible. |
Prior Authorization and Provider Billing Requirements
Prior authorization required; submit on Division standard form with required billing info
Prior authorization is required for injectable and infusible drugs and devices when they are dispensed in a prescriber's office or supplied to a member for self-administration. Requests must be submitted on the Division's standard prior-authorization form (no other form, including letterhead, will be accepted) and must include the billing information required in the billing instructions in Subchapter 5 of the Physician Manual. For pharmacy‑supplied items, the request must also include the pharmacy name, address, and telephone number. Submit all requests to the Division at the address provided in the bulletin.
- Use the Division's standard prior-authorization form; obtain from MassHealth Forms Distribution.
- Include billing information as required in Subchapter 5 of the Physician Manual.
- For pharmacy‑supplied items, include the MassHealth pharmacy name, address, and telephone number.
Enter administering physician's MassHealth provider number in Item 3; new PA if another provider administers
Item 3 of the prior-authorization form must show the MassHealth provider number of the physician who will administer the drug or device (do not enter a group practice number). If a different provider will administer the item, that provider must submit a new prior‑authorization request with their own MassHealth provider number and receive approval before administration; the provider name on the prior‑authorization must match the provider name on the claim or the Division will deny the claim.
- Do not enter the seven‑digit group practice number beginning with 97 in Item 3.
- A new prior authorization (with that provider's MassHealth number) is required if another provider will administer the drug or device.
- Provider name on the prior-authorization form must match the provider name on the claim.
Pharmacies may not dispense injectables/infusibles directly to members unless for self‑administration; office delivery billing allowed
Pharmacies must not dispense injectable or infusible drugs and devices directly to MassHealth members unless the item is intended for self-administration. As an alternative, a MassHealth pharmacy may bill for drugs or devices delivered to the office of the MassHealth physician who will administer them; physicians may bill for supplying these items in the office.
- Direct pharmacy-to-member dispensing of injectable/infusible items is prohibited unless for self-administration.
- Allowed payment/supply options: physician bills for office‑supplied items, or pharmacy bills for items delivered to the physician's office.
Defined Terms — Injectable/Infusible Items
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