Special and Regular Formula

1
Special and Regular Formula

• Members who have MassHealth and WIC Benefits

2
MassHealth Pays for Special Formula

• MassHealth and its contracted Managed Care
• Organizations (MCOs) pay for medically necessary
  special
• (prescription) formula for eligible members even
  if they are
• enrolled in WIC.
• Formula products may also be called enteral
  products, these
• include special and regular (non-prescription)
  formulas.

3
What are Special Formulas?

• Some examples of special formula are
• Nutramigen Lipil
• Neocate Infant
• Neosure Advance
• Pediasure
• Pregestimil Lipil
• PKU-2 or PKU-3
• There are many more that may be prescribed and
  usually are
• used if the infant, child or adult has some
  special health
• condition.

4
WIC Benefits

• Members who may be eligible for WIC benefits are
  children under 5 years old and women who are
  pregnant, breastfeeding or postpartum. They must
  meet income and nutritional risk criteria.
• WIC will continue to provide other components of
  the food package if MassHealth is paying for the
  formula and they will also provide nutrition
  education as well other services.

5
WIC Special Formula Process

• WIC staff will issue only ONE month of
  special formula checks to WIC participants who
  are enrolled in MassHealth. This will allow for
  the MassHealth prior authorization approval
  process to take place. In the case of any
  additional need where the approval for the PA has
  not yet been given, the WIC Program will continue
  to issue formula until the members formula is
  received from MassHealth.

6
WIC Regular Formula Process

• Regular (non- special) formula will continue to
  be provided by WIC.
• Regular formulas that WIC will continue to
  provide as first payer include
• Good Start Supreme
• Good Start Supreme DHA/ARA
• Good Start Supreme Soy DHA/ARA
• Enfamil Lipil with Iron
• Enfamil Lipil Low Iron
• ProSobee Lipil

7
When Regular Formula is Provided by MassHealth

• MassHealth, including its contracted Managed Care
  
• Organizations (MCOs), will provide coverage of
  medically
• necessary regular formula only under the
  following
• circumstances
• the member is not eligible for WIC or
• the member does not receive adequate amounts of
  regular formula from WIC to meet his or her
  medical needs

8
Process to Obtain Formula from MassHealth

• The patient visits the provider who determines
  that the member requires a special formula.
• The prescribing provider or the providers staff
  involved in the members care completes the
  necessary medical necessity form or letter and a
  prescription.
• The medical necessity form or letter and
  prescription must be signed and dated by the
  prescribing provider.

9
Documentation of Medical Necessity

• Clinical information may be completed by the
  clinician on the MassHealth Medical Necessity
  Review Form for Enteral Nutrition Products or on
  the providers letterhead. It must include all of
  the required information.
• The Medical Necessity Review Form for Enteral
  Nutrition Products, can be viewed at
  http//www.mass.gov/Eeohhs2/docs/masshealth/guidel
  ines/mnr_enteralnutrition.pdf

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Guidelines for Medical Necessity

• For additional information the provider can be
  referred to
• The Guidelines for Medical Necessity
  Determination for Enteral Nutrition Products
  which can be found at
• http//www.mass.gov/Eeohhs2/docs/masshealth/guidel
  ines/mg-enteralnutrition.pdf

12
Documentation Required to Obtain a Prior
Authorization

• The Prior Authorization must be submitted with
  the following
• Medical Necessity Review Form or letter of
  medical necessity on providers letterhead.
• Prescription indicating the number of refills and
  the number of units per day (for tube feeding
  the number of calories per day).
• Prior Authorization Request Form including the
  appropriate HCPC code and modifier (indicating if
  this is for oral or tube feeding).
• Manufacturers invoice if there is no established
  rate set.

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Submitting a Prior Authorization

• The documentation (medical necessity form and
  prescription) is either sent by the prescribing
  provider or taken by the member (or caregiver) to
  the Durable Medical Equipment (DME)
  provider/pharmacy.
• The DME provider/pharmacy submits the prior
  authorization (PA) request to MassHealth on the
  members behalf using the Automated Prior
  Authorization System (APAS) or using the standard
  paper PA form. The letter of medical necessity
  and prescription are submitted with the request.

15
Submitting a Prior Authorization
For instructions on the electronic submission
of a request for prior authorization, go to
MassHealths Automated Prior Authorization System
at www.masshealth-apas.com
16
Prior Approval Review Process

• The Prior Authorization (PA) Unit will review an
  appropriately completed PA request and determine
  if there is medical justification to determine if
  the formula is medically necessary.
• The Prior Authorization unit will notify the
  DME/pharmacy provider and the member within 15
  calendar days after a request for service.

17
What if the PA is Running Out?

• A new or updated prior authorization along with
  current medical necessity documentation/prescripti
  on must be requested for formula and must be
  submitted before the expiration of the current
  prior authorization to continue receiving the
  formula without a gap in service.

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Delivery

• The provider may deliver the formula to a
  members home but cant charge the member for the
  delivery. The delivery charge is incorporated
  into the fee set by the Department of Health Care
  Finance and Policy (DHCFP) regulations.

19
MCO Enrolled Members
Members enrolled in a MassHealth MCO and their
providers must contact the appropriate MCO
Customer Service Center for information about the
PA process.
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?Questions?

• Who pays for special formula if the member has
  both WIC and MassHealth benefits?
• Who can supply formula to a member?
• What forms does a prescriber need to provide to
  the DME/pharmacy vendor?
• What does the DME/pharmacy vendor need to do to
  get a PA approved?
• What do I do if Im contacted about a pharmacy
  provider who is reluctant to submit a PA request
  when presented with a prescription and medical
  necessity documentation?