FDA-approved, for example:

• Agitation associated with dementia due to Alzheimer’s Disease
• Bipolar disorder
• Hallucinations/delusions associated with Parkinson's Disease Psychosis
• Irritability associated with autistic disorder
• Major depressive disorder
• Schizoaffective disorder
• Schizophrenia
• Tourette syndrome

non-FDA-approved, for example:

• Autism spectrum disorders
• Bipolar disorder
• Schizoaffective disorder
• Schizophrenia
• Tourette syndrome

Note: The above lists may not include all FDA-approved and non-FDA-approved indications.

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 PA 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.

Abilify Asimtufii

• Documentation of all of the following is required for all members:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to Aristada; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits and polypharmacy requirements for Abilify Asimtufii will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for at least 90 days out of the last 120 days.^†

Abilify Maintena

• Documentation of all of the following is required for all members:
  • appropriate diagnosis; and
  • one of the following:
    • inadequate response, adverse reaction, or contraindication to Aristada; or
    • member refuses gluteal injections and requires a dose of Aristada that must be administered gluteally only (> 441 mg); and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits and polypharmacy requirements for Abilify Maintena will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for at least 90 days out of the last 120 days.^†

Abilify Mycite

• Documentation of all of the following is required for all members:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse reaction to one or contraindication to both of the following: Abilify Maintena and Aristada; and
  • medical necessity for monitoring member’s ingestion of oral aripiprazole as noted by one of the following:
    • requirement of witnessed or recorded medication ingestion; or
    • alternative medication adherence methods were insufficient, including all of the following: medication alarms or reminders, pill boxes, pill counts, refill frequency assessment; and
  • member has been trained to use the Abilify Mycite (aripiprazole tablet with sensor) system; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).
• For recertification, documentation of continued medical necessity for use instead of alternatives is required.

aripiprazole ODT

• Documentation of all of the following is required: 
  • appropriate diagnosis; and
  • medical necessity for the orally disintegrating formulation as noted by one of the following:
    • member has a swallowing disorder or condition affecting ability to swallow; or
    • need for witnessed administration; and
  • one of the following: 
    • requested quantity does not exceed established quantity limits (please refer to the reference table below); or
    • clinical rationale why the dose cannot be consolidated; or
    • clinical rationale why the member requires dosing at intervals exceeding the quantity limit.

aripiprazole solution for members ≥ 13 years of age and ≥ ten mL/day 

• Documentation of all of the following is required: 
  • appropriate diagnosis; and
  • medical necessity for the solution formulation as noted by one of the following:
    • member has a swallowing disorder or condition affecting ability to swallow; or
    • need for witnessed administration; and
  • one of the following: 
    • requested quantity does not exceed established quantity limits (please refer to the reference table below); or
    • requested quantity is ≥ ten mL/day and inadequate response, adverse reaction, or contraindication to aripiprazole ODT (at an equivalent dose to the requested dose).

asenapine sublingual tablet 

• Documentation of all of the following is required for all members: 
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to two or contraindication to all second-generation (atypical) antipsychotics; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits and polypharmacy requirements for asenapine sublingual tablet will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for two second-generation (atypical) antipsychotics or of the requested agent for 90 days out of the last 120 days.^†

Caplyta

• Documentation of all of the following is required for all members with a diagnosis of bipolar depression:
  • appropriate diagnosis; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below); and
  • one of the following: 
    • inadequate response, adverse reaction, or contraindication to both of the following: olanzapine monotherapy or in combination with fluoxetine, quetiapine immediate-release or extended-release; or
    • inadequate response or adverse reaction to two different or contraindication to all second-generation (atypical) antipsychotics; and
  • one of the following:
    • request is for Caplyta 42 mg capsule; or
    • for Caplyta 10.5 mg or 21 mg capsule, one of the following: 
      • member has hepatic impairment; or
      • member is utilizing a CYP3A4 inhibitor; or
      • member experienced side effects with the 42 mg dose; or
      • member has high sensitivity to antipsychotic medications and needs to be initiated on a lower dose.

• Documentation of all of the following is required for members < 18 years of age with a psychiatric diagnosis not listed above:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone; and
  • inadequate response or adverse reaction to two different or contraindication to all atypical and typical antipsychotics; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below); and
  • one of the following:
    • request is for Caplyta 42 mg capsule; or
    • for Caplyta 10.5 mg or 21 mg capsule, one of the following: 
      • member has hepatic impairment; or
      • member is utilizing a CYP3A4 inhibitor; or
      • member experienced side effects with the 42 mg dose; or
      • member has high sensitivity to antipsychotic medications and needs to be initiated on a lower dose.

• Documentation of all of the following is required for members ≥ 18 years of age with a psychiatric diagnosis not listed above: 
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to two or contraindication to all second-generation (atypical) antipsychotics; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).
  • one of the following:
    • request is for the 42 mg capsule; or
    • for Caplyta 10.5 mg or 21 mg capsule, one of the following: 
      • member has hepatic impairment; or
      • member is utilizing a CYP3A4 inhibitor; or
      • member experienced side effects with the 42 mg dose; or
      • member has high sensitivity to antipsychotic medications and needs to be initiated on a lower dose.

SmartPA: Claims within quantity limits and polypharmacy requirements for Caplyta will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for at least 90 days out of the last 120 days. Claims within quantity limits and polypharmacy requirements for Caplyta 42 mg for members < 18 years of age will also usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of one of the following second-generation (atypical) antipsychotics available without PA: aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone, and any two other atypical or typical antipsychotics. Claims within quantity limits and polypharmacy requirements for Caplyta 42 mg for members ≥ 18 years of age will also usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for two second-generation (atypical) antipsychotics.^†

clozapine ODT, risperidone ODT 3 mg and ODT 4 mg

• Documentation of all of the following is required for all members:
  • appropriate diagnosis; and
  • medical necessity for the orally disintegrating formulation as noted by one of the following:
    • member has a swallowing disorder or condition affecting ability to swallow; or
    • need for witnessed administration; or
    • intolerance to other formulations of the requested agent; and
  • for risperidone ODT 3 mg or ODT 4 mg, requested quantity does not exceed established quantity limits (please refer to reference table below).

Cobenfy

• Documentation of all of the following is required for all members:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • one of the following:
    • Cobenfy will be used as monotherapy; or
    • documentation of cross-taper plan if currently on antipsychotic therapy; and
  • one of the following:
    • member is at high risk for extrapyramidal side effects (EPS)/tardive dyskinesia (TD) with at least one of the following:
      • member is ≥ 55 years of age; or
      • history of EPS/TD with prior second-generation (atypical) antipsychotic use; or
    • all of the following:
      • member is at high risk for metabolic disease; and
      • inadequate response or adverse reaction to one or contraindication to all of the following: aripiprazole, lurasidone, ziprasidone; and
      • inadequate response or adverse reaction to one additional second generation (atypical) antipsychotic or contraindication to all second generation (atypical) antipsychotics; or
    • inadequate response or adverse reaction to two or contraindication to all second-generation (atypical) antipsychotics; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

Erzofri

• Documentation of all of the following is required for all members:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to Invega Sustenna; and
  • inadequate response, adverse reaction, or contraindication to one other long-acting injectable antipsychotic; and 
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits for Erzofri will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for at least 90 days out of the last 120 days.^†

Fanapt

• Documentation of all of the following is required for members < 18 years of age:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone; and
  • inadequate response or adverse reaction to two different or contraindication to all atypical and typical antipsychotics; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

• Documentation of all of the following is required for members ≥ 18 years of age: 
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to two or contraindication to all second-generation (atypical) antipsychotics; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits and polypharmacy requirements for Fanapt for members < 18 years of age will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of one of the following second-generation (atypical) antipsychotics available without PA: aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone, and any two other atypical or typical antipsychotics, or of the requested agent for at least 90 days out of the last 120 days. Claims within quantity limits and polypharmacy requirements for Fanapt for members ≥ 18 years of age will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for two second-generation (atypical) antipsychotics or of the requested agent for at least 90 days out of the last 120 days.^†

Lybalvi

• Documentation of all of the following is required for all members: 
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse reaction to two or contraindication to all second-generation (atypical) antipsychotics; and
  • both of the following:
    • member is not being treated with an opioid; and
    • member is not being treated for acute opioid withdrawal; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within specified quantity limits and polypharmacy requirements will usually process and pay at the pharmacy without PA if the member has a history of paid claims for the reference agent for at least 90 out of the last 120 days.^†

Nuplazid

• Documentation of all the following is required for all members:
  • appropriate diagnosis; and
  • prescriber is a neurologist (including neurology nurse practitioners or physician assistants) or consult notes (dated within one year) from a specialist are provided; and
  • for Nuplazid 10 mg tablet, requested medication will be used in combination with a strong CYP3A4 inhibitor; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

Opipza

• Documentation of all of the following is required: 
  • appropriate diagnosis; and
  • medical necessity for the orally disintegrating formulation as noted by one of the following:
    • member has a swallowing disorder or condition affecting ability to swallow; or
    • need for witnessed administration; and
  • inadequate response, adverse reaction, or contraindication to both of the following: aripiprazole ODT, aripiprazole solution; and
  • one of the following: 
    • requested quantity does not exceed established quantity limits (please refer to the reference table below); or
    • clinical rationale why the dose cannot be consolidated; or
    • clinical rationale why the member requires dosing at intervals exceeding the quantity limit.

perphenazine/amitriptyline and olanzapine/fluoxetine

• Documentation of all of the following is required for all members:
  • appropriate diagnosis; and
  • medical necessity for use of the combination product instead of the commercially available separate agents.

SmartPA: Claims for perphenazine/amitriptyline will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for at least 90 days of therapy out of the last 120 days.^†

Rexulti

• Documentation of all of the following is required for all members with a diagnosis of major depressive disorder (MDD) or treatment-resistant depression:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to two or contraindication to all antidepressants (either alone or in combination); and
  • Rexulti will be used as adjunctive antidepressant therapy; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

• Documentation of all of the following is required for all members with a psychiatric diagnosis not listed above: 
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to two or contraindication to all second-generation (atypical) antipsychotics; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits and polypharmacy requirements for Rexulti will usually process at the pharmacy without a PA request if the member has a diagnosis of major depressive disorder, a history of paid MassHealth pharmacy claims for any two antidepressants, and a history of paid MassHealth pharmacy claims for an antidepressant in the last 30 days. Claims within quantity limits and polypharmacy requirements for Rexulti will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for two second-generation (atypical) antipsychotics or of the requested agent for at least 90 days out of the last 120 days.^† 

Rykindo

• Documentation of all of the following is required for all members: 
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to all of the following: risperidone extended-release intramuscular injection (generic Risperdal Consta), Perseris, Uzedy; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within specified quantity limits will usually process and pay at the pharmacy without PA if the member has a history of paid claims for the reference agent for at least 90 days out of the last 120 days.^†

Secuado

• Documentation of all of the following is required for all members: 
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse reaction to two second-generation (atypical) antipsychotics; and
  • one of the following:
    • inadequate response or adverse reaction to asenapine sublingual; or
    • medical necessity for the transdermal formulation; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within specified quantity limits and polypharmacy requirements will usually process and pay at the pharmacy without PA if the member has a history of paid claims for the reference agent for at least 90 days out of the last 120 days.^†

Versacloz

• Documentation of all of the following is required for all members:
  • appropriate diagnosis; and
  • medical necessity for the oral suspension formulation as noted by one of the following: 
    • member has a swallowing disorder or condition affecting ability to swallow; or
    • need for witnessed administration; or
    • intolerance to other clozapine formulations.

Vraylar

• Documentation of all of the following is required for all members for adjunctive treatment for MDD or treatment-resistant depression:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to one or contraindication to all antidepressants (either alone or in combination); and
  • Vraylar will be used as adjunctive antidepressant therapy; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

• Documentation of all of the following is required for all members with a diagnosis of bipolar depression:
  • appropriate diagnosis; and
  • one of the following: 
    • inadequate response or adverse reaction to one or contraindication to both of the following: olanzapine monotherapy or in combination with fluoxetine, quetiapine immediate-release or extended-release; or
    • inadequate response or adverse reaction to one different or contraindication to all second-generation (atypical) antipsychotics; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

• Documentation of all of the following is required for all members with a psychiatric diagnosis not listed above:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: aripiprazole, clozapine, olanzapine, quetiapine, risperidone,  ziprasidone; and
  • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits and polypharmacy requirements for Vraylar will usually process at the pharmacy without a PA request if the member has a diagnosis of major depressive disorder, a history of paid MassHealth pharmacy claims for any one antidepressant, and a history of paid MassHealth pharmacy claims for an antidepressant in the last 30 days. Claims within quantity limits and polypharmacy requirements for Vraylar will usually process and pay at the pharmacy without prior authorization if the member has a history of a paid claim for the reference agent for at least 90 out of 120 days. Claims for Vraylar will usually also process and pay without prior authorization for members who have a history of paid claims for one of the following: aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone in all claims history.^†

Exceeding quantity limits (for all agents except aripiprazole ODT and solution, and Opipza)

• Documentation of all of the following is required for all members:
  • appropriate diagnosis; and
  • one of the following: 
    • clinical rationale why the dose cannot be consolidated; or
    • clinical rationale why the member requires dosing at intervals exceeding what is recommended by the FDA. 

Polypharmacy (overlapping pharmacy claims for two or more antipsychotics [includes first-generation and/or second-generation antipsychotics, except clozapine, Cobenfy, Nuplazid, and injectable formulations] for at least 60 days within a 90-day period) for members ≥ 18 years of age

• Documentation of all of the following is required:
  • psychiatric diagnosis including treatment-resistant conditions; and
  • treatment plan including names of current antipsychotics and corresponding diagnoses; and
  • prescriber is a specialist (e.g., psychiatrist, neurologist [including psychiatric/neurological nurse practitioners or physician assistants]) or consult notes (dated within one year) from a specialist are provided; and
  • one of the following:
    • inadequate response or adverse reaction to two monotherapy trials as clinically appropriate; or
    • member had a recent psychiatric hospitalization and was discharged on the current regimen; or
    • cross-titration/taper of antipsychotic therapy; or
    • member is stable on the current regimen.

In addition to individual drug PA criteria where applicable, some behavioral health medications are subject to additional polypharmacy and age limit restrictions.

Behavioral Health Medication Polypharmacy (pharmacy claims for any combination of four or more behavioral health medications [i.e., alpha₂ agonists, antidepressants, antipsychotics, armodafinil, atomoxetine, benzodiazepines, buspirone, cerebral stimulants, donepezil, hypnotic agents, memantine, meprobamate, modafinil, mood stabilizers (agents considered to be used only for seizure diagnoses are not included), naltrexone, prazosin, viloxazine, and xanomeline/trospium] within a 45-day period if one of the following is included: an antipsychotic, a benzodiazepine, divalproex/valproate, lithium, or a tricyclic antidepressant; or, pharmacy claims for any combination of five or more behavioral health medications [as defined  above] within a 45-day period) for members < 18 years of age

• For regimens including ≥ two mood stabilizers, documentation of the following is required:
  • one of the following:
    • member had a recent psychiatric hospitalization (within the last three months); or
    • member has a history of severe risk of harm to self or others; or
  • all of the following: 
    • appropriate diagnoses; and
    • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
    • prescriber is a specialist (e.g., psychiatrist, child adolescent psychiatrist [including psychiatric nurse practitioners], neurologist, pediatric neurologist, developmental and behavioral pediatrics) or consult is provided; and
    • if member has been on the requested agent for the past 12 months with no adjustments (i.e., dose decrease, attempted discontinuation), at least one of the following:
      • previous efforts to reduce/simplify the regimen in the past 24 months resulted in symptom exacerbation; or
      • family/caregiver does not support the regimen change at this time due to risk of exacerbation; or
      • other significant barrier for therapy discontinuation; and
    • one of the following:
      • member has a seizure diagnosis only; or
      • member has an appropriate psychiatric diagnosis, with or without seizure diagnosis, and one of the following:
        • cross-titration/taper of mood stabilizer therapy; or
        • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate; or
      • member has a diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain), with or without seizure diagnosis, and that other clinically appropriate therapies have been tried and failed; therefore, multiple mood stabilizers are needed; or
      • member has psychiatric and comorbid diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain), with or without seizure diagnosis, and that other clinically relevant therapies have been tried and failed; therefore, multiple mood stabilizers are needed, and one of the following:
        • cross-titration/taper of mood stabilizer therapy; or
        • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate.  

Antipsychotic Polypharmacy (overlapping pharmacy claims for 2 or more antipsychotics [includes first-generation and/or second-generation antipsychotics, except short-acting injectable formulations] for at least 60 days within a 90-day period) for members < 18 years of age

• For all requests, individual drug PA criteria must be met first where applicable.
• Documentation of the following is required:
  • one of the following:
    • member had a recent psychiatric hospitalization (within the last three months); or
    • member has a history of severe risk of harm to self or others; or
  • all of the following:
    • treatment plan including name, dose, and frequency of all current behavioral health medications, associated target symptom(s), and behavioral health diagnoses; and
    • a comprehensive behavioral health plan (i.e., non-pharmacologic interventions) is in place; and
    • prescriber is a specialist (e.g., psychiatrist, child adolescent psychiatrist [including psychiatric nurse practitioners], neurologist, pediatric neurologist, developmental and behavioral pediatrics) or consult is provided; and
    • stage of treatment is acute, maintenance, or discontinuation; and
    • one of the following:
      • for acute stage (initiation of antipsychotic treatment likely with subsequent dose adjustments to maximize response and minimize side effects), one of the following:
        • cross-titration/taper of antipsychotic therapy; or
        • inadequate response or adverse reaction to two monotherapy trials as clinically appropriate; or
      • for maintenance stage (response to antipsychotic treatment with goal of remission or recovery), all of the following:
        • regimen is effective, therapy benefits outweigh risks, and appropriate monitoring is in place; and
        • if member has been on the antipsychotic regimen for the last 12 months, clinical rationale for extended therapy including at least one of the following: previous efforts to reduce/simplify the antipsychotic regimen in the last 24 months resulted in symptom exacerbation; or family/caregiver does not support the antipsychotic regimen change at this time due to risk of exacerbation; or other significant barrier for antipsychotic therapy discontinuation; or
      • for discontinuation stage (clinically indicated that the antipsychotic regimen can likely be successfully tapered), cross-titration/taper of antipsychotic therapy.

Antipsychotic for members < ten years of age

• For all requests, individual drug PA criteria must be met first where applicable.
• Documentation of the following is required:
  • one of the following:
    • member had a recent psychiatric hospitalization (within the last three months); or
    • member has a history of severe risk of harm to self or others; or
    • for requests for aripiprazole or risperidone for members ≥ six years of age and < ten years of age, a diagnosis of autism spectrum disorder (ASD); or
  • all of the following:
    • complete medication treatment plan including name, dose, and frequency of all current behavioral health medications, associated target symptom(s), and behavioral health diagnoses; and
    • a comprehensive behavioral health treatment plan (i.e., non-pharmacological interventions) is in place; and
    • prescriber is a specialist (e.g., psychiatrist, child adolescent psychiatry [including psychiatric nurse practitioners], neurologist, pediatric neurology, developmental and behavioral pediatrics) or consult is provided; and
    • one of the following:
      • member is in acute stage of treatment (initiation of antipsychotic treatment likely with subsequent dose adjustments to maximize response and minimize side effects); or
      • all of the following:
        • member is in maintenance stage of treatment (response to antipsychotic treatment with goal of remission or recovery); and
        • regimen is effective, therapy benefits outweigh risks, and appropriate monitoring is in place; and
        • if member has been on the antipsychotic regimen for the last 12 months, clinical rationale for extended therapy including at least one of the following: previous efforts to reduce/simplify the antipsychotic regimen in the last 12 months resulted in symptom exacerbation; or family/caregiver does not support the antipsychotic regimen change at this time due to risk of exacerbation; or other significant barrier for antipsychotic therapy discontinuation; or
      • all of the following:
        • member is in discontinuation stage of treatment (clinically indicated that the antipsychotic regimen can likely be successfully tapered); and
        • cross-titration/taper of antipsychotic therapy.

Cobenfy for members < six years of age

• For all requests, individual drug PA criteria must be met first where applicable.
• Documentation of the following is required:
  • one of the following:
    • member had a recent psychiatric hospitalization (within the last three months); or
    • member has a history of severe risk of harm to self or others; or
  • all of the following:
    • appropriate diagnosis; and
    • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
    • prescriber is a specialist (e.g., psychiatrist, child adolescent psychiatrist [including psychiatric nurse practitioners], neurologist, pediatric neurologist, developmental and behavioral pediatrics) or consult is provided; and
    • if member has been on the requested agent for the past 12 months with no adjustments (i.e., dose decrease, attempted discontinuation), at least one of the following:
      • previous efforts to reduce/simplify the regimen in the past 24 months resulted in symptom exacerbation; or
      • family/caregiver does not support the regimen change at this time due to risk of exacerbation; or
      • other significant barrier for therapy discontinuation.

Reference Table:

^† 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.

Please see the following link to find out more information regarding Second-Generation (Atypical) Antipsychotics: https://www.mass.gov/lists/second-generation-antipsychotics-also-known-as-atypical-antipsychotics.