Skip to Content

Table 35: Antibiotics and Anti-Infectives - Oral and Inhaled


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: Infectious Disease Agents

Medication Class/Individual Agents: Antibiotics and Anti-Infectives

I. Prior-Authorization Requirements

 Anti-Infectives: Oral and Inhaled – Not Otherwise Classified

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

albendazole test   A90
  • Metronidazole is available in 250 mg and 500 mg tablets, and 375 mg capsules. Due to a considerable cost difference, metronidazole 375 mg capsules require prior authorization (PA).
  • Linezolid is FDA-approved for the treatment of gram-positive coccal infections including methicillin-resistant Staphylococcus aureus (MRSA). The Centers for Disease Control and Prevention (CDC) recommends that clinicians reserve linezolid for more severe infections after consultation with an infectious disease specialist or for those patients who have not responded to other antibiotics. Community-acquired MRSA has responded to a number of other antibiotics, including doxycycline, clindamycin, minocycline, and TMP/sulfamethoxazole. Vancomycin continues to be first-line treatment for hospital-acquired MRSA infections. Due to a considerable cost difference, linezolid suspension requires PA.
 
artemether / lumefantrine Coartem PA   - > 24 units/365 days
atovaquone Mepron test   # , A90
benznidazole test  
clindamycin capsule, injection, oral solution Cleocin test   # , A90
dapsone tablet test   A90
fidaxomicin Dificid PA  
fosfomycin Monurol test   # , A90
ivermectin tablet Stromectol test   #
linezolid suspension Zyvox PA   A90
linezolid tablet Zyvox test   # , A90
mebendazole PA   A90
methenamine Hiprex test   # , A90
metronidazole 250 mg, 500 mg tablet test   A90
metronidazole 375 mg capsule Flagyl PA   A90
metronidazole suspension Likmez PA  
nifurtimox Lampit PA  
nitazoxanide Alinia PA  
nitrofurantoin 25 mg/5 mL suspension Furadantin PA   A90
nitrofurantoin 50 mg/5 mL suspension PA   A90
nitrofurantoin macrocrystals Macrodantin test   # , A90
nitrofurantoin monohydrate / macrocrystals Macrobid test   # , A90
praziquantel Biltricide test   BP, A90
pyrantel pamoate Reese's Pinworm test  
pyrimethamine Daraprim PA   BP, A90
quinine Qualaquin test   # , A90
rifamycin Aemcolo PA  
rifaximin 200 mg Xifaxan test  
rifaximin 550 mg Xifaxan PA  
secnidazole Solosec PA  
tafenoquine Krintafel PA   - > 2 units/365 days
tedizolid tablet Sivextro PA  
tinidazole test   A90
triclabendazole Egaten PA  
trimethoprim tablet test   A90
vancomycin capsule Vancocin test   # , A90
vancomycin oral solution Firvanq test   BP, A90

 Antibiotics: Oral and Inhaled – Aminoglycosides

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

amikacin liposome inhalation Arikayce PA  

  

 
neomycin test   *, A90
paromomycin test   A90
tobramycin inhalation powder Tobi Podhaler PA  
tobramycin inhalation solution-Bethkis Bethkis PA   BP, A90
tobramycin inhalation solution-Kitabis Pak Kitabis Pak test   BP, A90
tobramycin inhalation solution-Tobi Tobi test   # , A90

 Antibiotics: Oral and Inhaled – Antitubercular Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

aminosalicylic acid Paser test  

  

 
bedaquiline Sirturo PA  
capreomycin Capastat test  
cycloserine test   A90
ethambutol Myambutol test   # , A90
ethionamide Trecator test  
isoniazid test   A90
pretomanid test   A90
pyrazinamide test   A90
rifabutin Mycobutin test   BP, A90
rifampin Rifadin test   # , A90
rifapentine Priftin test  

 Antibiotics: Oral and Inhaled – Cephalosporins

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

cefaclor capsule test   A90
  • Cefadroxil tablet requires PA. Cefadroxil capsule and suspension are less-costly alternatives and are available without PA.
  • Cefaclor is available as extended-release and immediate-release formulations. The immediate-release formulation is available without PA.
  • Cefpodoxime suspension requires PA. Cefpodoxime tablets are less costly and available without PA. Cefdinir, another third-generation cephalosporin, comes in a suspension formulation that is available without PA.
  • Cephalexin capsules are available in 250 mg, 500 mg, and 750 mg strengths. The 250 mg and 500 mg capsules are significantly less costly. PA is required for cephalexin 750 mg capsules.
 
cefaclor extended-release PA   A90
cefaclor suspension PA   A90
cefadroxil capsule, suspension test   A90
cefadroxil tablet PA   A90
cefdinir test   A90
cefixime Suprax PA   A90
cefpodoxime suspension PA   A90
cefpodoxime tablet test   A90
cefprozil test   A90
cefuroxime axetil test   A90
cephalexin 250 mg, 500 mg capsule, suspension test   A90
cephalexin 750 mg capsule PA   A90

 Antibiotics: Oral and Inhaled – Fluoroquinolones

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

ciprofloxacin 100 mg tablet PA   A90
  • Ciprofloxacin tablets are available in 100 mg, 250 mg, 500 mg, and 750 mg strengths. The 250 mg, 500 mg, and 750 mg strengths are significantly less costly. PA is required for ciprofloxacin 100 mg tablets.
 
ciprofloxacin injection, suspension, 250 mg, 500 mg, 750 mg tablet Cipro test   # , A90
delafloxacin tablet Baxdela PA  
levofloxacin test   A90
moxifloxacin tablet test   A90
ofloxacin tablet PA   A90

 Antibiotics: Oral and Inhaled – Macrolides

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

azithromycin injection, suspension, tablet Zithromax test   # , A90
  • Azithromycin is available as 250 mg and 500 mg tablets, 100 mg/5mL and 200 mg/5mL suspensions, and one gram powder packets. The tablet and suspension formulations are significantly less costly. PA is required for the one gram powder packet.
  • Clarithromycin is available in extended-release and immediate-release formulations. The immediate-release formulation is available without PA.
 
azithromycin powder packet Zithromax PA   A90
clarithromycin test   A90
clarithromycin extended-release PA   A90
erythromycin delayed-release capsule, tablet test   A90
erythromycin ethylsuccinate suspension Eryped test   # , A90
erythromycin stearate tablet test   A90
erythromycin tablet test   A90

 Antibiotics: Oral and Inhaled – Penicillins

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

amoxicillin test   A90
  • Amoxicillin/clavulanate is available as immediate-release and extended-release formulations. The extended-release formulation requires PA. In addition, amoxicillin/clavulanate 125/31.25 mg/5 mL suspension requires PA. The immediate-release tablets, chewable tablets, and select strengths of suspension are available without PA.
 
amoxicillin / clavulanate 125/31.25 mg/5 mL suspension Augmentin PA  
amoxicillin / clavulanate chewable tablet, 200/28.5, 250/62.5, 400/57, 600/42.9 mg/5 mL suspension, tablet Augmentin test   # , A90
amoxicillin / clavulanate extended-release Augmentin XR PA   A90
ampicillin test   A90
dicloxacillin test   A90
penicillin V test   A90

 Antibiotics: Oral and Inhaled – Sulfonamides

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

sulfadiazine test   A90

  

 
sulfamethoxazole / trimethoprim suspension Sulfatrim test   # , A90
sulfamethoxazole / trimethoprim tablet Bactrim test   #

 Antibiotics: Oral and Inhaled – Tetracyclines

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

demeclocycline test   A90

Oral antibiotics for the treatment of acne or rosacea:

  • Moderate acne can be managed with topical retinoids in combination with oral antibiotics and/or benzoyl peroxide.
  • Oral tetracyclines may be used for the management of papulopustular rosacea.
    • These agents are most useful for improving inflammatory papules and pustules, and may also reduce erythema.
 
doxycycline calcium syrup Vibramycin test  
doxycycline hyclate 100 mg capsule Vibramycin test   # , A90
doxycycline hyclate 100 mg tablet pack Lymepak PA  
doxycycline hyclate 20 mg, 100 mg tablet test   A90
doxycycline hyclate 50 mg capsule test   A90
doxycycline hyclate 50 mg tablet PA   A90
doxycycline hyclate 75 mg, 150 mg tablet PA   A90
doxycycline hyclate delayed-release 50 mg, 60 mg, 80 mg, 120 mg, 200 mg tablet Doryx PA   A90
doxycycline hyclate delayed-release 75 mg, 100 mg, 150 mg tablet PA   A90
doxycycline monohydrate 150 mg capsule PA   A90
doxycycline monohydrate 150 mg tablet PA   A90
doxycycline monohydrate 40 mg capsule PA   A90
doxycycline monohydrate 50 mg, 100 mg capsule test   A90
doxycycline monohydrate 50 mg, 75 mg, 100 mg tablet test   A90
doxycycline monohydrate 75 mg capsule PA   A90
doxycycline monohydrate suspension Vibramycin test   # , A90
minocycline capsule test   A90
minocycline extended-release 105 mg, 135 mg tablet Minolira PA   A90
minocycline extended-release 45 mg, 90 mg, 135 mg tablet PA   A90
minocycline extended-release 55 mg, 65 mg, 80 mg, 105 mg, 115 mg tablet Solodyn test   BP, A90
minocycline tablet PA   A90
omadacycline tablet Nuzyra PA  
tetracycline test   A90
Table Footnotes
# 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.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 
* The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without PA.
 
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.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Infections (site and location vary by indication for requested agent)

Non-FDA-approved, for example:

  • Infections (site and location vary by indication for requested agent)

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

Back to top


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 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.

 

Aemcolo

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • one of the following:
      • inadequate response or adverse reaction to one of the following: ciprofloxacin, levofloxacin; or
      • inadequate response, adverse reaction, or contraindication to azithromycin; or
      • contraindication to fluoroquinolones and azithromycin; and
    • inadequate response, adverse reaction, or contraindication to Xifaxan (rifaximin) 200 mg
    • requested quantity is ≤ 12 tablets/three days.

  

amoxicillin/clavulanate extended-release, azithromycin powder packet, cefaclor extended-release, cefaclor suspension, cefadroxil tablet, cefpodoxime suspension, cephalexin 750 mg capsule, ciprofloxacin 100 mg tablet, and metronidazole 375 mg capsule

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to one other clinically appropriate, less-costly antibiotic; and
    • medical necessity for the requested formulation instead of formulations available without PA.

  

Alinia tablet

  • Documentation of all of the following is required for a diagnosis of giardiasis: 
    • appropriate diagnosis; and
    • appropriate dosing; and
    • member is ≥ 12 years of age; and
    • inadequate response or adverse reaction to one or contraindication to both of the following: metronidazole, tinidazole.
  • Documentation of all of the following is required for a diagnosis of cryptosporidiosis: 
    • appropriate diagnosis; and
    • appropriate dosing; and
    • member is ≥ 12 years of age.
  • Documentation of all of the following is required for a diagnosis of Helicobacter pylori:
    • appropriate diagnosis; and
    • member is ≥ 12 years of age; and
    • inadequate response, adverse reaction, or contraindication to both of the following:
      • clarithromycin-based triple therapy containing metronidazole: proton pump inhibitor, clarithromycin, and metronidazole; and
      • bismuth quadruple therapy: proton pump inhibitor, bismuth subsalicylate, metronidazole, and tertracycline.

   

Alinia suspension

  • Documentation of all of the following is required for a diagnosis of giardiasis: 
    • appropriate diagnosis; and
    • appropriate dosing; and
    • member is ≥ one year of age; and
    • inadequate response or adverse reaction to one or contraindication to both of the following: metronidazole, tinidazole.
  • Documentation of all of the following is required for a diagnosis of cryptosporidiosis: 
    • appropriate diagnosis; and
    • appropriate dosing; and
    • member is ≥ one year of age.
  • Documentation of all of the following is required for a diagnosis of Helicobacter pylori:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to both of the following:
      • clarithromycin-based triple therapy containing metronidazole: proton pump inhibitor, clarithromycin, and metronidazole; and
      • bismuth quadruple therapy: proton pump inhibitor, bismuth subsalicylate, metronidazole, and tertracycline.


 

Arikayce

  • Documentation of all of the following is required:
    • appropriate diagnosis; and 
    • member is ≥ 18 years of age; and
    • member has completed a minimum of six consecutive months of a multidrug background regimen therapy; and
    • requested agent will be used as part of a combination antibacterial drug regimen to treat nontuberculous mycobacteria (Mycobacterium avium complex) lung disease; and
    • prescriber is a specialist (e.g., pulmonologist, infectious disease specialist) or consult notes from a specialist are provided.

 

Augmentin 125/31.25 mg/5mL suspension

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • one of the following:
      • member is < 12 weeks of age; or
      • requested dose is too difficult to measure using the 250/62.5 mg/5 mL formulation.

  

Baxdela tablet and Nuzyra tablet, for non-MRSA community acquired bacterial pneumonia (CABP)

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • inadequate response or adverse reaction to one or contraindication all of the following: amoxicillin, amoxicillin/clavulanate, ampicillin/sulbactam, azithromycin, cefotaxime, cefpodoxime, ceftriaxone, cefuroxime, clarithromycin, doxycycline, levofloxacin, moxifloxacin.

  

Baxdela tablet and Nuzyra tablet for suspected or confirmed MRSA acute bacterial skin and skin structure infection (ABSSSI) or suspected or confirmed mixed pathogen (including MRSA) ABSSSI

  • Documentation of all of the following is required:
    • appropriate diagnosis; and 
    • member is ≥ 18 years of age; and
    • one of the following:
      • culture is positive for MRSA and inadequate response or adverse reaction to one or contraindication to all of the following: sulfamethoxazole-trimethoprim, clindamycin, vancomycin IV, linezolid, doxycycline, minocycline; or
      • member has a history of past MRSA infection and inadequate response or adverse reaction to two or contraindication to all of the following: sulfamethoxazole-trimethoprim, clindamycin, vancomycin IV, linezolid, doxycycline, minocycline; and
    • for suspected or confirmed mixed pathogen infections (including MRSA), inadequate response, adverse reaction, or contraindication to one other antibiotic with gram negative coverage available without PA.

 

Baxdela tablet and Nuzyra tablet for suspected or confirmed mixed pathogen non-MRSA ABSSSI

  • Documentation of all of the following is required:
    • appropriate diagnosis; and 
    • member is ≥ 18 years of age; and 
    • inadequate response or adverse reaction to two or contraindication to all antibiotics with appropriate coverage for pathogens available without PA.

 

cefixime

  • Documentation of all of the following is required: 
    • appropriate diagnosis (e.g., genitourinary tract infections, respiratory tract infections, skin and skin structure infections); and
    • for suspension or chewable tablet, one of the following:
      • member is < 13 years of age; or
      • medical necessity for use of chewable tablet or suspension formulation instead of the capsule formulation; and
    • for capsules, requested quantity is ≤ one unit/day; and
    • one of the following:
      • inadequate response or adverse reaction to one or contraindication (e.g., culture not susceptible) to both of the following: cefdinir, cefpodoxime; or
      • member is completing a course of therapy which was initiated while a hospital inpatient.

SmartPA: Claims for cefixime capsule will usually process at the pharmacy without a PA request if the member has a history of MassHealth medical claims for a diagnosis of genitourinary tract infections, respiratory tract infections, or skin and skin structure infections, there is a history of at least one paid MassHealth pharmacy claim for cefdinir or cefpodoxime in the last 90 days and the current claim plus history ≤ one unit/day.

SmartPA: Claims for cefixime suspension will usually process at the pharmacy without a PA request if the member has a history of MassHealth medical claims for a diagnosis of genitourinary tract infections, respiratory tract infections, or skin and skin structure infections, member’s age < 13 years of age, and there is a history of at least one paid MassHealth pharmacy claim for cefdinir or cefpodoxime in the last 90 days.

SmartPA: Claims for cefixime chewable tablet will usually process at the pharmacy without a PA request if the member has a history of MassHealth medical claims for a diagnosis of genitourinary tract infections, respiratory tract infections, or skin and skin structure infections, member’s age < 13 years of age, there is a history of at least one paid MassHealth pharmacy claim for cefdinir or cefpodoxime in the last 90 days, and the current claim plus history ≤ one tablet/day.

  

Coartem > 24 units/365 days

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • medical necessity for exceeding the quantity limit.

   

Dificid

  • Documentation of all of the following is required:
    • diagnosis of clostridium difficile-associated diarrhea (CDAD) that is not considered to be fulminant disease; and
    • member is ≥ six months of age; and
    • appropriate dosing.

  

Doryx (doxycycline hyclate delayed-release 60 mg and 120 mg tablet),  doxycycline hyclate 50 mg, 75 mg, and 150 mg tablet, doxycycline hyclate delayed-release 50 mg, 75 mg, 80 mg, 100 mg, 150 mg, and 200 mg tablet, doxycycline monohydrate 40 mg and 75 mg capsule, and doxycycline monohydrate 150 mg capsule and tablet

  • Documentation of all of the following is required:  
    • appropriate diagnosis; and
    • inadequate response to one doxycycline hyclate or monohydrate formulation available without PA; and
    • medical necessity for the requested formulation instead of doxycycline formulations available without PA. 

  

Egaten

  • Documentation of all of the following is required:
    • diagnosis of Fascioliasis; and
    • member is ≥ six years of age; and
    • prescriber is an infectious disease specialist or consult notes from an infectious disease specialist regarding the use of the agent are provided; and
    • appropriate dosing.

 

Krintafel > 2 units/365 days

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • member is receiving the requested agent in combination with chloroquine therapy; and
    • medical necessity for exceeding the quantity limit.

 

Lampit

  • Documentation of all of the following is required for pediatric members:
    • appropriate diagnosis; and
    • member is < 18 years of age; and
    • appropriate dosing based on member weight; and
    • requested duration is ≤ 60 days; and
    • for members ≥ two to < 13 years of age, inadequate response, adverse reaction, or contraindication to benznidazole.
  • Documentation of all of the following is required for adult members:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • appropriate dosing based on member weight; and
    • requested duration is ≤ 90 days; and
    • inadequate response, adverse reaction, or contraindication to benznidazole.
  • For recertification, documentation of medical necessity for duration of therapy exceeding 60 days in pediatric members or 90 days in adult members.

    

Likmez

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • one of the following:
      • inadequate response, adverse reaction, or contraindication to metronidazole tablets; or
      • medical necessity for the requested formulation instead of formulations available without prior authorization.

 

 

linezolid suspension and Sivextro tablet

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • for linezolid suspension, medical necessity for use of the suspension formulation instead of the tablet formulation; and
    • one of the following:
      • vancomycin-resistant enterococcus (VRE) infection or suspected VRE infection and one of the following:
        • for Sivextro and one of the following:
          • inadequate response, adverse reaction, or contraindication to linezolid; or
          • culture is resistant to linezolid (if cultures can be obtained); or
        • for linezolid suspension; or
      • culture is positive for methicillin-resistant Staphylococcus aureus (MRSA) and inadequate response or adverse reaction to one or contraindication to all of the following: clindamycin, doxycycline, linezolid, minocycline, sulfamethoxazole/trimethoprim, vancomycin IV; or
      • member has a history of past MRSA infection and inadequate response or adverse reaction to two or contraindication to all of the following: clindamycin, doxycycline, linezolid, minocycline, sulfamethoxazole/trimethoprim, vancomycin IV.

 

Lymepak

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ eight years of age and weighs ≥ 45 kg; and
    • appropriate dosing; and
    • inadequate response, adverse reaction, or contraindication to all doxycycline formulations available without prior authorization; and
    • medical necessity for the requested formulation instead of doxycycline 100 mg formulations available without prior authorization.


mebendazole

  • Documentation of all of the following is required for a diagnosis of pinworm: 
    • appropriate diagnosis; and
    • appropriate dosing; and
    • inadequate response, adverse reaction, or contraindication to both of the following: albendazole, pyrantel pamoate.
  • Documentation of all of the following is required for a diagnosis of whipworm, hookworm, or roundworm:
    • appropriate diagnosis; and
    • appropriate dosing; and
    • inadequate response, adverse reaction, or contraindication to albendazole.

   

minocycline extended-release 45 mg, 90 mg, 135 mg tablet, minocycline tablet, and Minolira

  • Documentation of all of the following is required:  
    • appropriate diagnosis; and 
    • for minocycline immediate-release tablet, both of the following:
      • inadequate response to minocycline capsule; and 
      • medical necessity for the requested formulation instead of minocycline capsules; and
    • for minocycline extended-release tablet formulations, inadequate response, adverse reaction, or contraindication to both of the following: minocycline capsules, Solodyn. 

           

nitrofurantoin 25 mg/5 mL suspension and nitrofurantoin 50 mg/5 mL suspension

  • Documentation of all of the following is required:  
    • appropriate diagnosis; and
    • appropriate dosing; and
    • medical necessity for use of the suspension formulation instead of the capsule formulation.

       

ofloxacin

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to one of the following: ciprofloxacin, levofloxacin, moxifloxacin. 

       

pyrimethamine

  • Documentation of all of the following is required for toxoplasmosis treatment: 
    • appropriate diagnosis; and
    • appropriate dosing and frequency; and
    • requested agent will be used as combination therapy.
  • Documentation of all of the following is required for primary prophylaxis of toxoplasmosis:
    • indication is for primary prophylaxis of toxoplasmosis; and
    • appropriate dose and frequency; and
    • inadequate response, adverse reaction, or contraindication to trimethoprim-sulfamethoxazole; and
    • one of the following:
      • CD-4 count is < 200 cells/mm3; or
      • clinical rationale for prophylaxis; and
    • requested agent will be used as combination therapy.
  • Documentation of all of the following is required for secondary prophylaxis of toxoplasmosis:
    • indication is for secondary prophylaxis of toxoplasmosis; and
    • appropriate dose and frequency; and
    • one of the following:
      • CD-4 count is < 200 cells/mm3or
      • clinical rationale for prophylaxis; and
    • requested agent will be used as combination therapy.

   

Sirturo

  • Documentation of all of the following is required:  
    • appropriate diagnosis; and
    • requested agent will be used in combination with at least two other antitubercular agents.

    

Solosec

  • Documentation of all of the following is required for a diagnosis of bacterial vaginosis:
    • appropriate diagnosis; and 
    • member is ≥ 18 years of age; and 
    • appropriate dosing; and
    • inadequate response or adverse reaction to two or contraindication to all of the following: oral or vaginal metronidazole, oral or vaginal clindamycin, oral tinidazole.
  • Documentation of all of the following is required for a diagnosis of trichomoniasis:
    • appropriate diagnosis; and 
    • member is ≥ 18 years of age; and 
    • appropriate dosing; and
    • inadequate response or adverse reaction to one or contraindication to both of the following: oral metronidazole, oral tinidazole.

  

Tobi Podhaler

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to tobramycin inhalation solution (Kitabis Pak, Tobi).

 

tobramycin inhalation solution (Bethkis)

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to tobramycin inhalation solution (Kitabis Pak, Tobi). 

 

Xifaxan 550 mg

  • Documentation of all of the following is required for a diagnosis of hepatic encephalopathy:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • inadequate response, adverse reaction, or contraindication to lactulose; and
    • requested quantity is ≤ two tablets/day.
  • Docuentation of all of the following is required for a diagnosis of irritable bowel syndrome with diarrhea:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • appropriate dosing; and
    • inadequate response or adverse reaction to three or contraindication to all of the following: bile acid sequestrant, bismuth subsalicylate, bulk-forming agent, diphenoxylate/atropine, loperamide, tricyclic antidepressant (TCA).
  • Documentation of all of the following is required for a diagnosis of small intestinal bacterial overgrowth (SIBO):
    • appropriate diagnosis; and
    • member is ≥ 12 years of age; and
    • inadequate response or adverse reaction to one or contraindication to both of the following: amoxicillin-clavulanate, metronidazole added to either a cephalosporin or sulfamethoxazole-trimethoprim; and
    • appropriate dosing (550 mg three times daily for 14 days).

SmartPA: Claims for Xifaxan 550 mg (≤ two tablets/day) will usually process at the pharmacy without a PA request if the member has a history of MassHealth medical claims for a diagnosis of hepatic encephalopathy, member's age is ≥ 18 years of age, and a history of paid MassHealth pharmacy claims for lactulose.

   

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 plan.


Original Effective Date: 07/2008

Last Revised Date: 05/2024


Clinical Criteria Main Page | Back to topPrevious  |  Next

Last updated 06/24/24

Feedback