FDA-approved, for example:

• Ocular hypertension
• Open-angle glaucoma

Non-FDA-approved, for example:

• infantile hemangioma

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

Betimol

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to an ophthalmic timolol product available without PA.

SmartPA: Claims for Betimol will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for an ophthalmic timolol product that is available without PA.†

bimatoprost 0.03% ophthalmic solution, Lumigan 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to one or contraindication to both of the following: latanoprost solution, travoprost 0.004% eye drop.

brimonidine/timolol, ophthalmic

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to dorzolamide/timolol.

dorzolamide/timolol preservative free and Xelpros

• Documentation of the following is required:
  • appropriate diagnosis; and
  • sensitivity to benzalkonium chloride or any other preservative used in ophthalmic preparations.

Durysta

• Documentation of the following is required:
  • appropriate diagnosis; and
  • one of the following:
    • inadequate response or adverse reaction to Lumigan; or
    • medical necessity for the use of an implantable formulation as noted by one of the following:
      • limited dexterity; or
      • visual impairment; or
      • intellectual disability; and
  • affected eye(s) have not previously been treated with Durysta.

Iyuzeh and tafluprost

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to Xelpros; and
  • one of the following:
    • inadequate response, adverse reaction or contraindication to latanoprost solution available without PA; or
    • sensitivity to benzalkonium chloride or any other preservative used in ophthalmic preparations.

SmartPA: Claims for Iyuzeh or tafluprost will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for latanoprost solution available without PA and Xelpros.†

Rhopressa

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • one of the following:
    • inadequate response to combination therapy with a prostaglandin analog and an ophthalmic beta-blocker; or
    • contraindication or adverse reaction to prostaglandin analogs and ophthalmic beta-blockers; or
    • both of the following:
      • contraindication to ophthalmic beta-blockers; and
      • inadequate response or adverse reaction to a prostaglandin analog in combination with one of the following: ophthalmic alpha-2 adrenergic agonist, parasympathomimetic, carbonic anhydrase inhibitor; or
    • both of the following:
      • contraindication to prostaglandin analogs; and
      • inadequate response or adverse reaction to an ophthalmic beta-blocker in combination with one of the following: ophthalmic alpha-2 adrenergic agonist, parasympathomimetic, carbonic anhydrase inhibitor.

Rocklatan

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • one of the following:
    • inadequate response to combination therapy with a prostaglandin analog and an ophthalmic beta-blocker; or
    • both of the following:
      • contraindication to ophthalmic beta-blockers; and
      • inadequate response or adverse reaction to a prostaglandin analog in combination with one of the following: ophthalmic alpha-2 adrenergic agonist, parasympathomimetic, carbonic anhydrase inhibitor.

timolol ophthalmic gel forming solution

• Documentation of the following is required for diagnosis of ocular hypertesion or open-angle glaucoma:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to an ophthalmic timolol-containing product available without PA.
• Documentation of the following is required for diagnosis of infantile hemangioma: 
  • appropriate diagnosis.

SmartPA: Claims for timolol ophthalmic gel forming solution will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for an ophthalmic timolol-containing product.†

timolol ophthalmic unit dose solution

• Documentation of the following is required:
  • appropriate diagnosis; and
  • one of the following:
    • inadequate response or adverse reaction to an ophthalmic timolol product available without PA; or 
    • sensitivity to benzalkonium chloride.

SmartPA: Claims for timolol ophthalmic unit dose solution will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for an ophthalmic timolol product that is available without a PA.†

Vyzulta

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 17 years of age; and
  • one of the following:
    • inadequate response to combination therapy with latanoprost solution and an ophthalmic beta-blocker; or
    • both of the following:
      • inadequate response to latanoprost solution; and
      • contraindication or adverse reaction to an ophthalmic beta-blocker.

† 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.