FDA-approved, for example:

• spastic conditions
• adjunctive treatment to rest, physical therapy, and other measures for the relief of discomforts associated with acute, painful musculoskeletal disorders.

Note: The above list may not include all 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.

baclofen oral solution, baclofen suspension, and Lyvispah

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • one of the following:
    • medical necessity for the requested formulation as noted by one of the following:
      • member is < 13 years of age; or
      • requested dose is not available in the tablet formulation; or
      • swallowing disorder or condition affecting ability to swallow; or
    • inadequate response or adverse reaction to baclofen tablets; and
  • for Lyvispah, one of the following:
    • requested quantity is ≤ four units/day; or
    • both of the following:
      • medical necessity for exceeding four units/day; and
      • requested dose is consolidated.

baclofen 15 mg tablet

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • medical necessity for requested agent instead of baclofen tablets available without PA.

carisoprodol and carisoprodol-containing products

• Documentation of all of the following is required:
  • medical records documenting an inadequate response, adverse reaction, or contraindication to all of the following: baclofen, chlorzoxazone, cyclobenzaprine, dantrolene, metaxalone, methocarbamol, orphenadrine, tizanidine; and
  • member is ≥ 18 years of age; and
  • one of the following:
    • requested agent is being used for an acute condition; or
    • clinical rationale for the use of carisoprodol for the treatment of a chronic condition.

Spastic Conditions

Brand-name products (Dantrium, Zanaflex tablets) and tizanidine capsules 

• Documentation of the following is required:
  • diagnosis of a spastic condition; and
  • for brand name Dantrium or Zanaflex, the prescriber must provide documentation of an inadequate response, adverse reaction, or contraindication to dantrolene, baclofen, and tizanidine tablets; and
  • for a brand name drug with an A-rated generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to a generic equivalent of the requested product; and
  • for tizanidine capsules, both of the following:
    • inadequate response, adverse reaction, or contraindication to both of the following: baclofen, tizanidine tablets; and
    • medical necessity for capsule formulation (2 mg and 4 mg) or for dose (6 mg).

Musculoskeletal Conditions

chlorzoxazone 250 mg, 375 mg, 750 mg, cyclobenzaprine 7.5 mg, cyclobenzaprine extended-release, metaxalone, and orphenadrine/aspirin/caffeine

• Documentation of the following is required:
  • diagnosis of musculoskeletal condition; and
  • inadequate response, adverse reaction, or contraindication to all of the following: cyclobenzaprine immediate-release, orphenadrine, methocarbamol, chlorzoxazone 500 mg; and
  • one of the following:
    • member is ≥ 18 years of age; or
    • inadequate response, adverse reaction, or contraindication to acetaminophen; and
    • inadequate response or adverse reaction to two NSAIDS or contraindication to all NSAIDS; and
  • for orphenadrine/aspirin/caffeine, medical necessity for the combination product instead of the commercially available separate agents; and
  • for a brand name drug (with or without an A-rated generic) the prescriber must provide medical records documenting an inadequate response or adverse reaction to a generic equivalent of the requested drug.

Please note: requests for cyclobenzaprine extended-release require medical records of a trial with cyclobenzaprine immediate-release. Chlorzoxazone 250 mg, 375 mg, and 750 mg requests require medical records of a trial with  chlorzoxazone 500 mg.

SmartPA: Claims for metaxalone will usually process at the pharmacy without a PA request if the member has a history of MassHealth medical claims for a musculoskeletal disorder and paid MassHealth pharmacy claims for the following drugs: cyclobenzaprine immediate-release, orphenadrine, methocarbamol, and chlorzoxazone for members ≥ 18 years of age.^†

chlorzoxazone 500 mg < 18 years of age cyclobenzaprine 5 mg, 10 mg < 15 years of age, methocarbamol < 16 years of age, and orphenadrine < 18 years of age:

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to acetaminophen; and
  • inadequate response or adverse reaction to two or contraindication to all NSAIDs.

^†  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.