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.

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.