FDA-approved:

• Acute pain
• Ankylosing spondylitis 
• Familial adenomatous polyposis (FAP) 
• Juvenile rheumatoid arthritis
• Mild-to-moderate pain
• Moderate to moderately severe pain
• Osteoarthritis
• Primary dysmenorrhea
• Rheumatoid arthritis

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.
• 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 or requested medication (see below). 

Cambia

• Documentation of the following is required:
  • diagnosis of migraine; and
  • one of the following:
    • medical records documenting an inadequate response or adverse reaction to three different NSAIDs, one of which must be diclofenac sodium; or
    • for members with a swallowing disorder or condition affecting the ability to swallow tablets, an inadequate response or adverse reaction to ibuprofen suspension and naproxen suspension.

diclofenac/misoprostol for members < 60 years of age

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • medical records documenting an inadequate response or adverse reaction with concurrent therapy of diclofenac (minimum of 50 mg twice daily) and misoprostol (minimum of 200 mcg twice daily).

diclofenac potassium 25 capsule, diclofenac potassium 25 mg tablet, Zorvolex

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • an inadequate response or adverse reaction to an oral diclofenac product that does not require prior authorization; and 
  • an inadequate response or adverse reaction to two other different NSAIDs.

diclofenac topical patch (generic Flector)

• Documentation of the following is required:
  • diagnosis of acute pain (caused by minor strains, sprains, and contusions) or osteoarthritis; and
  • an inadequate response or adverse reaction to diclofenac 1% gel.

Elyxyb

• Documentation of all of the following is required:
  • appropriate diagnosis; and 
  • one of the following:
    • inadequate response or adverse reaction to celecoxib capsules; or
    • medical necessity for the use of the solution formulation as noted by one of the following:
      • requested dose is not available in the capsule formulation; or
      • 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.

etodolac ER, ketoprofen ER, naproxen CR

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical necessity for an extended-release formulation instead of the immediate release equivalent.

fenoprofen, meclofenamate, salsalate, tolmetin

• Documentation of the following is required:   
  • an appropriate diagnosis; and
  • an inadequate response or adverse reaction to three different oral NSAIDs.

ibuprofen powder

• Documentation of the following is required:
  • appropriate diagnosis; and
  • clinical rationale why other commercially available alternatives cannot be used.

ibuprofen/famotidine for members < 60 years of age

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical records documenting an inadequate response or adverse reaction with concurrent therapy of ibuprofen (minimum of 800 mg three times daily) and famotidine (minimum of 20 mg three times daily).

Indocin suspension for all ages, and naproxen suspension for members ≥ 13 years of age

• Documentation of the following is required:                   
  • an appropriate diagnosis; and
  • an inadequate response, adverse reaction, or contraindication to ibuprofen suspension; and
  • medical necessity for the use of the solution formulation as noted by one of the following:
    • requested dose is not available in the capsule formulation; or
    • member utilizes tube feeding (G-tube/J-tube); or
    • member has a swallowing disorder or condition affecting ability to swallow; or
    • for indocin suspension, member is <13 years of age.

ketorolac (tablets and injection) > 20 units/month

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • an inadequate response or adverse reaction to three different NSAIDs; and
  • clinical rationale for exceeding FDA-approved dosing/duration.  

ketorolac nasal spray

• Documentation of the following is required:
  • diagnosis of moderate to moderately severe pain; and
  • one of the following:
    • medical necessity for a non-oral NSAID formulation; or
    • an inadequate response or adverse reaction to two different NSAIDs and medical records documenting an inadequate response or adverse reaction to ketorolac tablets or injection; and
  • one of the following:
    • request is within quantity limit of five bottles/30 days.

Licart

• Documentation of the following is required:
  • diagnosis of acute pain (caused by minor strains, sprains, and contusions) or osteoarthritis; and
  • an inadequate response or adverse reaction to diclofenac 1% gel; and
  • an inadequate response or adverse reaction to diclofenac topical patch (generic Flector).

meloxicam capsule

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • an inadequate response or adverse reaction to meloxicam tablet; and
  • an inadequate response or adverse reaction to two other different NSAIDs; and
  • request is within quantity limit of one unit/day.

naproxen/esomeprazole for members < 60 years of age

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • medical records documenting an inadequate response or adverse reaction with concurrent therapy of naproxen (minimum of 375 mg twice daily) and omeprazole (minimum of 20 mg twice daily).  

Relafen DS

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • medical records documenting an inadequate response or adverse reaction to an equivalent dose of nabumetone 500 mg or 750 mg; and
  • inadequate response or adverse reaction to two other different 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.