Note:
The LMR displays information based on the payor selected in the eligibility box. If the patient has multiple payors, select other payors at the drop-down list to determine the best plan to use for each medication.
Patients with pharmacy benefits from MassHealth and Harvard Pilgrim include "Unknown" in the payor field. Formulary guidance and co-pay information is also unavailable (listed as "U" - Unknown). To access prior authorization forms for MassHealth, click here. To access forms for Harvard Pilgrim, click here.
Traffic light indicators
Traffic light indicators display to the left of the medication name to identify insurance formulary preference based on the eligibility status of the patient, according to MA-Share eligibility for this medication. The absence of an indicator means that the medication was not found in the database for MA-Share, was entered as free-text, or the eligibility status for this patient is unknown. The indicators are:
On formulary, and preferred
On formulary, not preferred
Non-formulary, not reimbursable,
excluded, or not covered
U Unknown; no formulary status available
Retail Copay column
This indicator is displayed to the right of the traffic light indicator, as follows:
Tier - Insurance plan uses a tier system for copay. For example, a detailed description could indicate Tier 1 of 3, for example.
Flat - Insurance plan uses a flat copay system. A detailed description could indicate $10, where the plan has a flat co-payment of ten dollars.
Percent - Insurance plan uses a percent copay system. A detailed description could indicate 20%, where the plan requires a co-payment equal to 20% of the cost of the medication.
Note: The flat and percent indicators can be used in combination (such as "$10 + 20%," meaning the cost to the patient is $10 plus 20% the cost of the medication).
Restrictions
Restrictions are listed in the far right column, just to the left of Alternates, and can include any of the following:
AL - Age limitations
DE - Product coverage exclusions.
GL - Limitations based on gender.
MN - Covered only if there is a documented medical necessity.
PA - Prior authorization required.
Note: To access prior authorization forms for Mass Health, click here. To access forms for Harvard Pilgrim, click here.
QL - Quantity limitations.
RD - Resource information at the drug level, provides a URL link to the patient's insurance website. May be a direct link for general information, or additional information specific to an above listed restriction.
RS - Resource information at a medication or therapeutic class summary level, provides a URL link to the patient's insurance website. May be a direct link for general information, or additional information specific to an above listed restriction.
SM - Step medications must be tried before this medication is covered.
ST - Medication is part of a step therapy approach to coverage.
TM - Text message with additional information for the provider.