651 CMR 15.08 - Formulary

651 CMR 15.08 applies only to the Formulary developed and maintained by the Plan. Members of a Medicare Part D Plan shall refer to their Medicare Part D Plan Formulary to determine its rules and the included Prescription Drugs.

(1) The Plan will develop and maintain a Plan Formulary consisting of a list of Prescription Drags. The Plan Formulary shall include insulin and disposable insulin syringes and needles. The Plan shall maintain a toll-free telephone number during business hours through which an Applicant or Member or his or her authorized representative may determine whether a particular Prescription Drag is included on the Plan Formulary.

(2) The Plan shall review the Plan Formulary and modify it as appropriate.

(3) The Plan shall not exclude any Prescription Drug from the Plan Formulary unless a Therapeutically Equivalent Prescription Drug is included on the Plan Formulary; however, the Secretary may exclude certain outpatient Prescription Drags or classes of outpatient Prescription Drags upon a written determination pursuant to M.G.L. 19A, § 39(r) that the exclusion is necessary to maintain the fiscal viability of the program.

(4) Excluded from the Plan Formulary are Prescription Drags labeled "Caution - limited by federal law to investigational use" or experimental drags.

(5) To ensure appropriate use of Covered Benefits, the Plan may require Prior Authorization and/or implement benefit management tools, including quantity limitations for certain Prescription Drags.

(6) Members shall have the right to seek a Review of the following:

(a) a Member's request to obtain a Non-preferred drug at the Co-payment level of a Preferred Drug;

(b) a Member's request to add to the Plan Formulary a Prescription Drug excluded from the Plan Formulary; or

(c) a Member's request to gain access to a Prescription Drag excluded from the Plan Formulary at Plan Formulary rates.

Notes

651 CMR 15.08

Amended by Mass Register Issue 1327, eff. 12/2/2016. Amended by Mass Register Issue 1408, eff. 1/10/2020.