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Introduction to Clinical Criteria

The Criteria for Prior Authorization identify the clinical information MassHealth considers when determining medical necessity for selected medications.  The criteria are based upon generally accepted standards of practice, review of the medical literature, federal and state policies, as well as laws applicable to the Massachusetts Medicaid Program. The clinical information included in the criteria is not intended to serve as a source of comprehensive prescribing information. Due to the logistics of updating the criteria, they may not contain all currently accepted indications and criteria used to treat the MassHealth population.

MassHealth reviews prior authorization (PA) requests on the basis of medical necessity only. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other insurance, and program restrictions.

MassHealth encourages the use of specialized prior-authorization request forms for certain drugs or drug classes.  These forms were created to highlight the information MassHealth considers when evaluating a request. The specialized forms have the name of the drug or drug class in the title. If there is no specialized form, please use the standard Drug Prior Authorization Request form. All forms are available at **All requests for prior authorization must be submitted and signed by a medical professional licensed to prescribe medications.**

The MassHealth Pharmacy Online Processing System (POPS) utilizes diagnosis codes from medical claims for some drug classes when processing claims at pharmacies. This means that a prescriber may not need to submit a paper prior authorization form if a member’s diagnosis and/or pharmacy claims in POPS meet the criteria for that drug.  Instances where this will occur are described within the Criteria.

Note to MassHealth Members:   This document was prepared for medical professionals to assist them in submitting documentation supporting the medical necessity of proposed treatment. Some language used in this communication may be unfamiliar to other readers; in this case, contact your health care provider for guidance or explanation.

Glossary of Terms

  • Adverse Reaction - Any undesirable or unwanted consequence of a drug (e.g., allergic response)
  • Claims – When used in the context of the Criteria, claims are requests for payment submitted to the MassHealth Pharmacy Online Processing System (POPS) by pharmacies
  • Contraindication – Any special symptom or circumstance that renders the use of a drug inadvisable, usually because of risk
  • Conventional Products – Those drugs which are generally accepted as useful for a condition because of standards of practice
  • Dose Consolidation – Instances where the number of tablets for a prescription can be decreased while keeping the dose the same (e.g., two 10mg tablets once a day can be consolidated to one 20mg once a day)
  • Inadequate Response – Insufficient effect of a drug when used at appropriate doses for an appropriate time period (dependent on drug class and/or drug)
  • Medical Necessity – Please see MassHealth regulations at  130 CMR 450.204.