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Table 33: Inflammatory Bowel Disease Agents


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Drug Category: Inflammatory Bowel Disease Agents

Medication Class/Individual Agents: Inflammatory Bowel Disease Agents

I. Prior-Authorization Requirements

 Inflammatory Bowel Disease Agents

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

balsalazide Colazal test   # , A90
budesonide 3 mg delayed-release capsule test   A90
budesonide extended-release capsule Ortikos PA  
budesonide extended-release tablet Uceris test   BP, A90
budesonide rectal foam Uceris PA   A90
hydrocortisone enema Cortenema test   # , A90
hydrocortisone foam Cortifoam test  
hydrocortisone hemorrhoidal cream Anusol-HC test   # , A90
mesalamine 0.375 gram extended-release capsule Apriso test   BP, A90
mesalamine 1.2 gram delayed-release tablet Lialda PA   A90
mesalamine 250 mg, 500 mg controlled-release capsule Pentasa test   BP, A90
mesalamine 400 mg delayed-release capsule Delzicol DR PA   A90
mesalamine 800 mg delayed-release tablet PA   A90
mesalamine enema Rowasa test   # , A90
mesalamine kit Rowasa Kit PA   A90
mesalamine suppository Canasa test   # , A90
olsalazine Dipentum test  
sulfasalazine Azulfidine test   # , A90
sulfasalazine delayed-release Azulfidine EN-Tabs test   # , A90

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.

 
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.
 
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:

  • Crohn’s disease
  • Ulcerative colitis

Note: The above list may not include all FDA-approved indications.

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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.

   

budesonide rectal foam

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • inadequate response (defined by at least three weeks of therapy) or adverse reaction to one or contraindication to both of the following: hydrocortisone enema, hydrocortisone foam.

SmartPA: Claims for budesonide rectal foam 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 60 days out of the last 90 days.

   

mesalamine 400 mg delayed-release capsule

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 5 years of age; and
    • inadequate response or adverse reaction to one or contraindication to all mesalamine oral formulations available without PA; and
    • appropriate dosing.

SmartPA: Claims for mesalamine 400 mg delayed-release capsule 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 60 days out of the last 90 days.

   

mesalamine 800 mg delayed-release tablet

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • inadequate response or adverse reaction to one or contraindication to all mesalamine oral formulations available without PA; and
    • appropriate dosing.

SmartPA: Claims for mesalamine 800 mg delayed-release tablet 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 60 days out of the last 90 days.

   

mesalamine 1.2 gram delayed-release tablet

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member's current weight is ≥ 24 kg; and
    • inadequate response or adverse reaction to one or contraindication to all mesalamine oral formulations available without PA; and
    • appropriate dosing.

SmartPA: Claims for mesalamine 1.2 gram delayed-release tablet 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 60 days out of the last 90 days.   

   

mesalamine enema kit

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to mesalamine enema and mesalamine suppository.

SmartPA: Claims for mesalamine enema kit 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 60 days out of the last 90 days.   

   

Ortikos

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • appropriate dosing; and
    • inadequate response or adverse reaction to one or contraindication to all budesonide oral formulations available without PA; and
    • one of the following:
      • member is ≥ 18 years of age; or
      • both of the following:
        • member is ≥ eight years of age; and
        • agent will be used for treatment of active Crohn’s disease.

SmartPA: Claims for Ortikos 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 60 days out of the last 90 days.

 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.


Original Effective Date: 04/2003

Last Revised Date: 04/2025


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Last updated 04/15/25

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