FDA-approved, for example:

• Allergic rhinitis
• Nasal polyps
• Nasal polyps and a history of ethmoid sinus surgery
• Non-allergic rhinitis

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.

flunisolide nasal spray (one inhaler/30 days), mometasone nasal spray (one inhaler/30 days), and Qnasl (one inhaler/30 days) for members six years of age and older

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • inadequate response (defined as at least 14 days of therapy), adverse reaction, or contraindication to budesonide OTC, fluticasone propionate 50 mcg, and triamcinolone OTC nasal sprays.

SmartPA: Claims for flunisolide nasal spray, mometasone nasal spray, and Qnasl for members ≥ six years will usually process at the pharmacy without a PA request if the claim is for ≤ one inhaler/30 days and the member has a history of paid MassHealth pharmacy claims for budesonide OTC, fluticasone propionate 50 mcg, and triamcinolone OTC nasal sprays.^†

flunisolide nasal spray (one inhaler/30 days), mometasone nasal spray (one inhaler/30 days), and Qnasl (one inhaler/30 days), for members four and five years of age

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • inadequate response (defined as at least 14 days of therapy), adverse reaction, or contraindication to fluticasone propionate 50 mcg and triamcinolone OTC nasal sprays.

Smart PA: Claims for flunisolide nasal spray, mometasone nasal spray, and Qnasl for members ages four or five years of age will usually process at the pharmacy without a PA request if the claim is for ≤ one inhaler/30 days and the member has a history of paid MassHealth pharmacy claims for fluticasone propionate 50 mcg and triamcinolone OTC nasal sprays.^†

flunisolide nasal spray (one inhaler/30 days), mometasone nasal spray (one inhaler/30 days), and Qnasl (one inhaler/30 days) for members less than four years of age

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • inadequate response (defined as at least 14 days of therapy), adverse reaction or contraindication to triamcinolone OTC nasal spray.

Smart PA: Claims for flunisolide nasal spray, mometasone nasal spray, and Qnasl for members < four years of age will usually process at the pharmacy without a PA request if the claim is for ≤ one inhaler/30 days and the member has a history of paid MassHealth pharmacy claims for triamcinolone OTC nasal spray.^†

flunisolide nasal spray (> one inhaler/30 days), mometasone nasal spray (> one inhaler/30 days), Qnasl (> one inhaler/30 days), Ryaltris (> one inhaler/30 days), Xhance (> one inhaler/30 days), and Zetonna (>one inhaler/30 days)

• Documentation of all of the following is required:
  • member must meet age-specific criteria for the individual agent requested (see approval criteria for individual agent); and
  • medical records demonstrating an inadequate response to an adequate trial of the manufacturer’s recommended doses; and
  • inadequate response (defined as at least 14 days of therapy) or adverse reaction to two or contraindication to all of the following: azelastine, cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, olopatadine.

Beconase AQ (> one inhaler/30 days), fluticasone propionate 50 mcg (> one inhaler/30 days), and Omnaris (> one inhaler/30 days)

• Documentation of all of the following is required:
  • medical records demonstrating an inadequate response to an adequate trial of the manufacturer’s recommended doses; and
  • inadequate response (defined as at least 14 days of therapy) or adverse reaction to two or contraindication to all of the following: azelastine, cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, olopatadine.

Ryaltris (one inhaler/30 days)

• Documentation of all of the following is required:
  • member is ≥ 12 years of age; and
  • appropriate diagnosis; and
  • one of the following:
    • inadequate response (defined as at least 14 days of therapy) or adverse reaction to one intranasal corticosteroid agent used in combination with one intranasal antihistamine agent; or
    • inadequate response (defined by at least 14 days of therapy), adverse reaction, or contraindication to azelastine/fluticasone propionate nasal spray.

Sinuva

• Documentation of all of the following is required:
  • member is ≥ 18 years of age; and
  • appropriate diagnosis; and
  • prescriber is an otolaryngologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to an oral corticosteroid and an inadequate response (defined as at least 14 days of therapy) or adverse reaction to an intranasal corticosteroid; or
    • contraindication to oral corticosteroids and an inadequate response (defined as at least 14 days of therapy) or adverse reaction to two intranasal corticosteroids.

Xhance (one inhaler/30 days)

• Documentation of all of the following is required:
  • member is ≥ 18 years of age; and
  • appropriate diagnosis; and
  • medical necessity for use of Xhance instead of all other intranasal corticosteroids.

Zetonna (one inhaler/30 days)

• Documentation of all of the following is required:
  • member is ≥ 12 years of age; and
  • appropriate diagnosis; and 
  • inadequate response (defined as at least 14 days of therapy), adverse reaction, or contraindication to budesonide OTC, fluticasone propionate 50 mcg, and triamcinolone OTC nasal sprays.

SmartPA: Claims for Zetonna for members ≥ 12 years will usually process at the pharmacy without a PA request if the claim is for ≤ one inhaler/30 days and the member has a history of paid MassHealth pharmacy claims for budesonide OTC, fluticasone propionate 50 mcg, and triamcinolone OTC nasal sprays.^†

^†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.