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.

orlistat, Saxenda, and Wegovy

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 12 years of age; and
  • appropriate dosing; and
  • member weight (dated within the last 90 days prior to treatment initiation); and
  • member will continue reduced-calorie diet and increased physical activity; and
  • for Saxenda and Wegovy, the requested agent will not be used in combination with another GLP-1 receptor agonist; and
  • one of the following:
    • for Saxenda, requested quantity is ≤ five pens/30 days; or
    • for Wegovy (semaglutide), requested quantity is ≤ four pens/28 days; or
    • for orlistat, requested quantity is ≤ three units/day; and
  • one of the following:
    • member BMI is ≥30 kg/m2 (dated within the last 90 days prior to treatment initiation); or
    • both of the following: 
      • member is ≥ 12 years and ≤ 17 years of age; and
      • member BMI is in the 95th percentile or greater (dated within the 90 days prior to treatment initiation); or
    • both of the following:
      • member BMI is ≥27 kg/m2 (dated within the last 90 days prior to treatment initiation); and
      • one of the following weight-related comorbid conditions:
        • coronary heart disease or other atherosclerotic disease; or
        • dyslipidemia; or
        • hypertension; or
        • non-alcoholic steatohepatitis (NASH); or
        • obstructive sleep apnea; or
        • systemic osteoarthritis; or
        • type 2 diabetes mellitus.

• For recertification, documentation of the following is required:
  • member weight (dated within the last 90 days); and
  • one of the following:
    • weight loss of ≥ 5% from baseline body weight; or
    • both of the following:
      • improvement in secondary measures; and
      • clinical rationale for continuation of therapy.

phentermine 37.5 mg capsule, tablet, benzphetamine, diethylpropion, diethylpropion ER, Lomaira, phentermine 15 mg, 30 mg capsule, phendimetrazine ER, phendimetrazine

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 17 years of age; and
  • member weight (dated within the last 90 days prior to treatment initiation); and
  • member will continue reduced-calorie diet and increased physical activity; and
  • one of the following:
    • for diethylpropion ER, phendimetrazine ER, phentermine 15mg, 30mg capsule, or phentermine 37.5 mg capsule or tablet, requested quantity is ≤ one unit/day; or
    • for benzphetamine, diethylpropion, Lomaira® or phendimetrazine, requested quantity is ≤ three units/day; and
  • for benzphetamine, diethylpropion, diethylpropion ER, phendimetrazine, and phendimetrazine ER, inadequate response or adverse reaction to one or contraindication to both of the following: Saxenda,Wegovy; and
  • one of the following:
    • member BMI is ≥ 30 kg/m2 (dated within the last 90 days prior to treatment initiation); or
    • both of the following:
      • member BMI is ≥27 kg/m2 (dated within the last 90 days prior to treatment initiation); and
      • one of the following weight-related comorbid conditions:
        • coronary heart disease or other atherosclerotic disease; or
        • dyslipidemia; or
        • hypertension; or
        • non-alcoholic steatohepatitis (NASH); or
        • obstructive sleep apnea; or
        • systemic osteoarthritis; or
        • type 2 diabetes mellitus.