FDA-approved, for example:

• Aspergillosis, blastomycosis, and histoplasmosis – Tolsura
• invasive Aspergillus infections – Cresemba, voriconazole suspension
• prevention of invasive Aspergillus and Candida infections – posaconazole injection, posaconazole oral suspension
• candidemia – Rezzayo, voriconazole suspension
• disseminated candidiasis  – voriconazole suspension
• esophageal candidiasis – voriconazole suspension
• fungal infections caused by Fusarium and Scedosporium – voriconazole suspension
• invasive candidiasis – Rezzayo
• oropharyngeal candidiasis –  Oravig, posaconazole oral suspension
• recurrent vulvovaginal candidiasis – Brexafemme, Vivjoa
• vulvovaginal candidiasis – Brexafemme
• zygomycosis (mucormycosis) – Cresemba

Non FDA-approved, for example:

• Aspergillus endophthalmitis and keratitis – voriconazole suspension
• esophageal candidiasis – posaconazole oral suspension
• fungal infections caused by Fusarium and Scedosporium – Cresemba
• oropharyngeal candidiasis – voriconazole suspension
• prevention of invasive Aspergillus and Candida infections – voriconazole suspension
• zygomycosis (mucormycosis) – posaconazole injection, posaconazole oral suspension

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.

Brexafemme

• Documentation of the following is required for the treatment of acute vulvovaginal candidiasis:
  • appropriate diagnosis; and
  • member is post-menarchal; and
  • one of the following:
    • inadequate response, adverse reaction, or contraindication to oral fluconazole; or
    • Candida species is fluconazole-resistant. 

• Documentation of the following is required for the treatment of recurrent vulvovaginal candidiasis:
  • appropriate diagnosis; and
  • results of a diagnostic test (e.g., KOH, nucleic acid probe-based test system, nucleic acid amplification, etc.) to confirm diagnosis; and 
  • member has had ≥ 3 acute VVC episodes within the last 12 months; and 
  • requested quantity is ≤ 24 tablets for one course of therapy; and 
  • member is post-menarchal; and
  • one of the following:
    • inadequate response (defined as ≥ 24 weeks of therapy or recurrence of infection while on maintenance therapy), adverse reaction, or contraindication to oral fluconazole; or 
    • candida species is fluconazole-resistant.

     Cresemba

• Documentation of the following is required for the treatment of aspergillus infections:
  • appropriate diagnosis; and
  • one of the following:
    • for the capsule formulation, member is ≥ six years of age and weighs ≤ 16 kg; or
    • for the injection formulation, member is ≥ one year of age; and
  • inadequate response, adverse reaction, or contraindication to both of the following: posaconazole, voriconazole; and
  • for the injection formulation, medical necessity for the requested formulation as noted by one of the following:
    • member is < 13 years of age; or
    • member utilizes tube feeding (G-tube/J-tube); or
    • member has a swallowing disorder or condition affecting ability to swallow.

• Documentation of the following is required for the treatment of zygomycosis (mucormycosis):
  • appropriate diagnosis; and
  • one of the following:
    • for the capsule formulation, member is ≥ six years of age and weighs ≤ 16 kg; or
    • for the injection formulation, member is ≥ one year of age; and
  • for the injection formulation, medical necessity for the requested formulation as noted by one of the following:
    • member is < 13 years of age; or
    • member utilizes tube feeding (G-tube/J-tube); or
    • member has a swallowing disorder or condition affecting ability to swallow; and
  • inadequate response, adverse reaction, or contraindication to posaconazole. 

SmartPA: Claims for Cresemba capsule will usually process at the pharmacy without a PA request for members who are ≥ 18 years of age and with one of the following: a history of MassHealth medical claims for zygomycosis (mucormycosis) within the last 365 days with history of paid claims for posaconazole within the last 90 days, or a history of MassHealth medical claims for aspergillosis within the last 365 days with history of paid claims for posaconazole and voriconazole within the last 90 days.^†

Oravig

• Documentation of the following is required for the diagnosis of oropharyngeal candidiasis:
  • appropriate diagnosis; and
  • member is ≥  two years of age; and
  • inadequate response, adverse reaction, or contraindication to all of the following: clotrimazole troches, fluconazole suspension or tablet, nystatin suspension or tablet.

posaconazole injection

• Documentation of the following is required for the prevention of invasive aspergillus and candida fungal infections:
  • member has a diagnosis of one of the following:
    • hematologic malignancy (e.g., acute myelogenous leukemia, myelodysplastic syndromes) with neutropenia; or
    • hematopoietic stem cell transplantation (HSCT); or
    • graft-versus-host disease (GVHD); and
  • member is ≥  two years of age; and
  • medical necessity for the requested formulation as noted by one of the following:
    • member is < 13 years of age; or
    • member utilizes tube feeding (G-tube/J-tube); or
    • member has a swallowing disorder or condition affecting ability to swallow.

• Documentation of the following is required for the treatment of invasive aspergillosis fungal infections:
  • appropriate diagnosis; and
  • member is ≥ 13 years of age; and
  • medical necessity for the requested formulation 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.

• Documentation of the following is required for the treament of zygomycosis (mucormycosis):
  • appropriate diagnosis; and
  • member is ≥ 13 years of age; and
  • medical necessity for the requested formulation 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.

posaconazole oral suspension

• Documentation of the following is required for the prevention of invasive aspergillus and candida fungal infections:
  • member has a diagnosis of one of the following:
    • hematologic malignancy (e.g., acute myelogenous leukemia, myelodysplastic syndromes) with neutropenia; or
    • hematopoietic stem cell transplantation (HSCT); or
    • graft-versus-host disease (GVHD); and
  • member is ≥ 13 years of age; and
  • medical necessity for the requested formulation 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.

• Documentation of the following is required for the treatment of esophageal candidiasis:
  • appropriate diagnosis; and
  • member is ≥ 13 years of age; and
  • inadequate response, adverse reaction, or contraindication to all of the following: oral fluconazole, itraconazole, voriconazole; and
  • medical necessity for the requested formulation 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.

• Documentation of the following is required for the treatment of oropharyngeal candidiasis:
  • appropriate diagnosis; and
  • member is ≥ 13 years of age; and
  • inadequate response, adverse reaction, or contraindication to both of the following: oral fluconazole, itraconazole; and
  • medical necessity for the requested formulation 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. 

• Documentation of the following is required for the treatment of zygomycosis (mucormycosis):
  • appropriate diagnosis; and
  • member is ≥ 13 years of age; and
  • medical necessity for the requested formulation 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.

 posaconazole powder for oral suspension

• Documentation of the following is required for the prevention of invasive aspergillus and candida fungal infections:
  • member has a diagnosis of one of the following:
    • hematologic malignancy (e.g., acute myelogenous leukemia, myelodysplastic syndromes) with neutropenia; or
    • hematopoietic stem cell transplantation (HSCT); or
    • graft-versus-host disease (GVHD); and
  • member is ≥  two and < 18 years of age; and
  • member is ≤ 40 kg; and
  • medical necessity for the requested formulation as noted by one of the following:
    • member is < 13 years of age; or
    • member utilizes tube feeding (G-tube/J-tube); or
    • member has a swallowing disorder or condition affecting ability to swallow.

    Rezzayo

• Documentation of all of the following is required:
  • member has a diagnosis of one of the following:
    • candidemia; or
    • invasive candidiasis; and
  • member is ≥ 18 years of age; and
  • prescriber is an infectious disease specialist or consult notes from a specialist are provided; and
  • inadequate response, adverse reaction, contraindication, or Candida isolate is resistant to all of the following: anidulafungin, caspofungin, micafungin; and
  • requested quantity is ≤ six vials for one course of therapy.

     Tolsura

• Documentation of the following is required for the treatment of aspergillosis, blastomycosis, and histoplasmosis:
  • appropriate diagnosis; and
  • medical necessity for the requested formulation instead of the 100 mg capsule and oral suspension.

Vivjoa

• Documentation of the following is required for the treatment of recurrent vulvovaginal candidiasis:
  • appropriate diagnosis; and
  • results of a diagnostic test (e.g., KOH, nucleic acid probe-based test system, nucleic acid amplification, etc.) to confirm diagnosis; and
  • member has had ≥ three acute VVC episodes within past 12 months; and
  • requested quantity is ≤ 18 capsules for one course of therapy; and 
  • one of the following:
    • member is ≥ 12 years of age and not of reproductive potential; or
    • member is post-menopausal; and
  • one of the following:
    • inadequate response (defined as ≥24 weeks of therapy or recurrence of infection while on maintenance therapy), adverse reaction, or contraindication to oral fluconazole; or
    • Candida species is fluconazole resistant.

voriconazole suspension

• Documentation of the following is required for the prevention of invasive aspergillus and candida fungal infections:
  • member has a diagnosis of one of the following:
    • hematologic malignancy (e.g., acute myelogenous leukemia, myelodysplastic syndromes) with neutropenia; or
    • hematopoietic stem cell transplantation (HSCT); or
    • graft-versus-host disease (GVHD).

• Documentation of the following is required for the treatment of aspergillus, scedosporium, and fusarium infections:
  • appropriate diagnosis.

• Documentation of the following is required for the treatment of aspergillus endophthalmitis and keratitis:
  • appropriate diagnosis.

• Documentation of the following is required for the treatment of candidemia and disseminated candidiasis infections:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to oral fluconazole.

• Documentation of the following is required for the treatment of esophageal candidiasis:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to both of the following: oral fluconazole, itraconazole.

• Documentation of the following is required for the treatment of oropharyngeal candidiasis:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to all of the following: oral fluconazole, itraconazole, posaconazole.

SmartPA: Claims for voriconazole suspension will usually process at the pharmacy without a PA request for members with a history of MassHealth medical claims for aspergillus within the last 365 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.