Prior authorization is required. The prescriber must obtain PA for the drug in order for the provider to receive reimbursement. Note: PA applies to both the brand-name and the FDA "A"-rated generic equivalent of listed product.

This designates a brand-name drug with FDA “A”-rated generic equivalents. PA is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.

Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.

Carve-Out. This agent is listed on the Acute Hospital Carve-Out Drugs List and is subject to additional monitoring and billing requirements. All requests for one-time cell and gene therapies (as listed on the Acute Hospital Carve-Out Drug List), including for members enrolled in an Accountable Care Partnership Plan (ACPP) or Managed Care Organization (MCO), will be reviewed by the MassHealth Drug Utilization Review (DUR) Program.

Preferred Drug. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class.

The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without PA.

PA status depends on the drug's formulation.

This drug is available through the health care professional who administers the drug or in an outpatient or inpatient hospital setting. MassHealth does not pay for this drug to be dispensed through the retail pharmacy. If listed, PA does not apply through the acute hospital inpatient setting, unless on the APAD/APEC carve-out drug list, or in the emergency, trauma, or urgent acute hospital outpatient settings. Please refer to 130 CMR 433.408 for PA requirements for other health care professionals. Notwithstanding the above, this drug may be an exception to the unified pharmacy policy; please refer to respective MassHealth Accountable Care Partnership Plans (ACPPs) and Managed Care Organizations (MCOs) for PA status and criteria, if applicable.

Product may be available through the Massachusetts Department of Public Health (DPH). Please check with DPH for availability. MassHealth does not pay for immunizing biologicals (i.e., vaccines) and tubercular (TB) drugs that are available free of charge through local boards of public health or through the Massachusetts Department of Public Health without PA (130 CMR 406.413(C)). In cases where free vaccines are available to providers for specific populations (e.g. children, high risk, etc.), MassHealth will reimburse the provider only for individuals not eligible for the free vaccines. Notwithstanding the above, MassHealth will pay pharmacies for seasonal flu vaccine serum without PA, if the vaccine is administered in the pharmacy.

Allowable 90-day supply. Dispensing in up to a 90-day supply is allowed. May not include all strengths or formulations. Quantity limits and other restrictions may apply.

Compounded pharmaceutical products with a total allowed ingredient cost greater than or equal to $100 require PA. In addition, compounded pharmaceutical products with intradermal, topical, or transdermal route of administration (ROA) require PA. The following ROAs are excluded from the PA requirement for products with a total allowed ingredient cost greater than or equal to $100: infusion, intramuscular, intravenous, intravenous piggyback, intravenous push, subcutaneous. Compounded pharmaceutical products utilizing any PA-requiring agent or not covered ingredient as part of the compound require PA.

Mandatory 90-day supply. After dispensing up to a 30-day supply initial fill, dispensing in a 90-day supply is required. May not include all strengths or formulations. Quantity limits and other restrictions may also apply.

Preferred Non-Drug Product. This product is a preferred non-drug product for which MassHealth has entered into a rebate agreement with product manufacturer.