FDA-approved, for example:

• perennial or seasonal allergic rhinitis: oral/intranasal antihistamines
• chronic idiopathic urticaria: oral antihistamines only
• vasomotor (i.e., non-allergic) rhinitis: oral/intranasal agents

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.

azelastine 0.15% (generic Astepro) and olopatadine (generic Patanase) nasal sprays

• Documentation of all of the following is required:  
  • appropriate diagnosis; and
  • inadequate response (defined as ≥ 14 days of therapy), or adverse reaction to one, or contraindication to all intranasal corticosteroid agents; and
  • inadequate response (defined as ≥ 14 days of therapy), adverse reaction, or contraindication to azelastine 137 mcg nasal spray.
• For quantities greater than one bottle/30 days, in addition to the above criteria, documentation must be provided regarding an inadequate clinical response at the manufacturer's recommended doses.

SmartPA: Claims for one bottle/30 days of azelastine 0.15% nasal spray and olopatadine nasal spray will usually process at the pharmacy without a PA request if the member has MassHealth medical claims for allergic rhinitis or non-allergic rhinitis and a history of paid pharmacy claims for ≥ 14 days out of the last 180 days of one intranasal corticosteroid and azelastine 137 mcg nasal spray.

carbinoxamine 6 mg tablet and Karbinal ER

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • inadequate response (defined as ≥ 14 days of therapy), or adverse reaction to one, or contraindication to all intranasal corticosteroid agents; and 
  • inadequate response (defined as ≥ 14 days of therapy), or adverse reaction to two, or contraindication to all nonselective antihistamines available without prior authorization; and
  • for Karbinal ER, inadequate response (defined as ≥ 14 days of therapy) or adverse reaction to carbinoxamine immediate-release solution; and
  • for carbinoxamine 6 mg tablet, inadequate response or adverse reaction to carbinoxamine 4 mg tablet. 

Clarinex-D

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • inadequate response (defined as ≥ 14 days of therapy), or adverse reaction to one, or contraindication to all intranasal corticosteroid agents (if the diagnosis is chronic idiopathic urticaria, a trial with an intranasal corticosteroid is not required); and
  • inadequate response (defined as ≥ 14 days of therapy), adverse reaction, or contraindication to both of the following: loratadine/pseudoephedrine and cetirizine/pseudoephedrine.

SmartPA: Claims for Clarinex-D will usually process at the pharmacy without a PA request if the member has MassHealth medical claims for allergic rhinitis or chronic idiopathic urticaria and a history of paid pharmacy claims for ≥ 14 days out of the last 180 days of loratadine/pseudoephedrine, cetirizine/pseudoephedrine, and an intranasal corticosteroid.

desloratadine tablet

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • inadequate response (defined as ≥ 14 days of therapy) or adverse reaction to one or contraindication to all of the following: cetirizine, fexofenadine, levocetirizine, and loratadine.

SmartPA: Claims for desloratadine tablets will usually process at the pharmacy without a PA request if the member has MassHealth medical claims for allergic rhinitis or chronic idiopathic urticaria and a history of paid pharmacy claims for ≥ 14 days out of the last 180 days for one of the following: loratadine tablets or liquid, cetirizine tablets or liquid, fexofenadine tablet, or levocetirizine tablet. 

desloratadine ODT and levocetirizine solution

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • medical necessity for use of requested agent as noted by 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; and
  • inadequate response (defined as ≥ 14 days of therapy) or adverse reaction to two or contraindication to all of the following: cetirizine, levocetirizine, and loratadine.

dexchlorpheniramine solution

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to two antihistamine solutions available without prior authorization.

^†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.