Table 6: Nutrients, Vitamins, and Vitamin Analogs
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Drug Category: Vitamin supplementation and management
Medication Class/Individual Agents: Vitamins and Nutrients
I. Prior-Authorization Requirements
Nutrients, Vitamins, and Vitamin Analogs – Not Otherwise Classified |
Clinical Notes |
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Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.
Vitamin D and Vitamin D Analogs:
calcifediol:
cyanocobalamin (generic Nascobal):
doxercalciferol:
paricalcitol:
potassium chloride powder for oral solution2,3:
1 Kidney Disease Improving Global Outcomes. KDIGO Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) [guideline on the Internet]. Kidney international supplements, 2017 [cited 2018 May 31]. Available from: https://kdigo.org/wp-content/uploads/2017/02/2017-KDIGO-CKD-MBD-GL-Update.pdf. 2 Lexicomp Online Database [database on the Internet]. Hudson (OH): Lexicomp Inc.; 2024 [cited 2024 Apr 10]. Available from: http://online.lexi.com. Subscription required to view. 3 Pokonza [package insert]. Hazlet (NJ): Carwin Pharmaceutical Associates, LLC; 2024 Mar. 4 Zemplar [package insert on the internet]. North Chicago (IL): AbbVie, Inc.; 2016 Oct [cited 2016 Dec 14]. Available from: www.zemplar.com.
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Nutrients, Vitamins, and Vitamin Analogs – Vitamin D Analogs |
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Nutrients, Vitamins, and Vitamin Analogs – Vitamins |
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# | 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. |
* | The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without PA. |
o | PA status depends on the drug's formulation. |
MB | 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 hospital outpatient and inpatient 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. |
A90 | 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. |
M90 | 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. |
II. Therapeutic Uses
FDA-approved, for example:
- Secondary hyperparathyroidism in chronic kidney disease (CKD)
- Short bowel syndrome
- Vitamin deficiency
Note: The above list may not include all FDA-approved indications.
III. Evaluation Criteria for Approval
Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.
- All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
- Dispensing in a 90-day supply of medication may be mandated or allowable for agents in this therapeutic class (designated by M90 or A90, respectively, in the Drug Notes section above). Applicable quantity limits are described below as units per day, per month, per 28 days, or as clinically appropriate, and may be extrapolated for fills of longer day supply.
- A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
- For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
- Additional criteria may apply depending upon diagnosis and/or requested medication (see below). Other factors, including rebate and FDA-approval status, may change independently of scheduled MassHealth updates, which may result in additional restrictions.
Adek Gummies, Dekas Bariatric, Dekas Essential, and Dekas Plus
- Documentation of the following is required:
- appropriate diagnosis (e.g., cystic fibrosis, short gut syndrome, malabsorption syndrome).
SmartPA: Claims for Adek Gummies, Dekas Bariatric, Dekas Essential, and Dekas Plus will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for the requested agent within the last 90 days, or if the member has a history of MassHealth medical claims for cystic fibrosis, malabsorption syndrome, or short gut syndrome.†
calcitriol solution
- Documentation of all of the following is required:
- appropriate diagnosis; and
- one of the following:
- member utilizes tube feeding (G-tube/J-tube); or
- member has a swallowing disorder or condition affecting ability to swallow; or
- member is < 13 years of age.
cyanocobalamin (generic Nascobal)
- Documentation of all of the following is required:
- appropriate diagnosis; and
- inadequate response, adverse reaction, or contraindication to all other comparable cyanocobalamin and vitamin B12 preparations available without prior authorization.
doxercalciferol capsule and paricalcitol capsule
- Documentation of all of the following is required:
- appropriate diagnosis; and
- appropriate age (for doxercalciferol capsule member is ≥ 18 years of age, for paricalcitol capsule member is ≥ ten years of age); and
- inadequate response (defined as ≥ 90 days of therapy), adverse reaction, or contraindication to both of the following: Vitamin D, calcitriol; and
- for doxercalciferol, inadequate response (defined as ≥ 90 days of therapy), adverse reaction, or contraindication to paricalcitol.
glucose products for members ≥ 19 years of age
- Documentation of all of the following is required:
- appropriate diagnosis; and
- medical necessity for the requested agent above age limit.
Pokonza
- Documentation of all of the following is required:
- appropriate diagnosis; and
- inadequate response, adverse reaction, or contraindication to both of the following: potassium bicarbonate, potassium chloride oral solution; and
- for members ≥ 13 years of age, inadequate response, adverse reaction, or contraindication to both of the following: potassium chloride extended-release capsule, potassium chloride extended-release tablet; and
- one of the following:
- inadequate response, adverse reaction, or contraindication to potassium chloride 20 mEq powder packet at an equivalent requested dose; or
- requested dose cannot be achieved without using Pokonza.
- For recertification, documentation that the member meets the criteria above is required.
Rayaldee
- Documentation of all of the following is required:
- appropriate diagnosis; and
- member is ≥ 18 years of age; and
- total 25-hydroxyvitamin D level is < 30 ng/mL; and
- inadequate response (defined as ≥ 90 days of therapy), adverse reaction, or contraindication to all of the following: vitamin D, calcitriol, paricalcitol; and
- appropriate dosing.
† Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.
Original Effective Date: 03/2006
Last Revised Date: 08/2024
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Last updated 08/12/24