FDA-approved:

• Acute pain
• Ankylosing spondylitis 
• Familial adenomatous polyposis (FAP) 
• Juvenile rheumatoid arthritis
• Mild-to-moderate pain
• Moderate to moderately severe pain
• Osteoarthritis
• Primary dysmenorrhea
• Rheumatoid arthritis

Non-FDA-approved:

• Cutaneous mastocytosis
• Mast cell activiation
• Migraine

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.

diclofenac/misoprostol for members < 60 years of age

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical records documenting an inadequate response or adverse reaction with concurrent therapy of diclofenac (minimum of 50 mg twice daily) and misoprostol (minimum of 200 mcg twice daily).

diclofenac potassium 25 capsule, diclofenac potassium 25 mg tablet, Zorvolex

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to an oral diclofenac product available without PA; and 
  • inadequate response or adverse reaction to two other different NSAIDs.

diclofenac powder for solution

• Documentation of the following is required:
  • diagnosis of migraine; and
  • one of the following:
    • medical records documenting an inadequate response or adverse reaction to three different NSAIDs, one of which must be diclofenac sodium; or
    • for members with a swallowing disorder or condition affecting the ability to swallow tablets, an inadequate response or adverse reaction to both of the following: ibuprofen suspension, naproxen suspension.

diclofenac topical patch (generic Flector)

• Documentation of the following is required:
  • diagnosis of acute pain (caused by minor strains, sprains, and contusions) or osteoarthritis; and
  • inadequate response or adverse reaction to diclofenac 1% gel.

Elyxyb

• Documentation of all of the following is required:
  • appropriate diagnosis; and 
  • one of the following:
    • inadequate response or adverse reaction to celecoxib capsules; or
    • medical necessity for the use of the solution formulation as noted by one of the following:
      • requested dose is not available in the capsule formulation; or
      • 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.

etodolac ER, ketoprofen ER, naproxen CR

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical necessity for an extended-release formulation instead of the immediate-release equivalent.

fenoprofen, meclofenamate, salsalate, tolmetin

• Documentation of the following is required:   
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to three different oral NSAIDs.

ibuprofen/famotidine for members < 60 years of age

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical records documenting an inadequate response or adverse reaction with concurrent therapy of ibuprofen (minimum of 800 mg three times daily) and famotidine (minimum of 20 mg three times daily).

Indocin suspension for all ages, and naproxen suspension for members ≥ 13 years of age

• Documentation of the following is required:                   
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to ibuprofen suspension; and
  • medical necessity for the use of the solution formulation as noted by one of the following:
    • requested dose is not available in the capsule formulation; or
    • member utilizes tube feeding (G-tube/J-tube); or
    • member has a swallowing disorder or condition affecting ability to swallow; or
    • for indocin suspension, member is <13 years of age.

ketorolac (tablets and injection) > 20 units/30 days

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to three different NSAIDs; and
  • clinical rationale for exceeding FDA-approved dosing/duration.  

ketorolac nasal spray

• Documentation of the following is required for a diagnosis of moderate to moderately severe pain:
  • appropriate diagnosis; and
  • one of the following:
    • medical necessity for a non-oral NSAID formulation; or
    • inadequate response or adverse reaction to two different NSAIDs and medical records documenting an inadequate response or adverse reaction to one of the following: ketorolac tablets, ketorolac injection; and
  • requested quantity is ≤ five bottles/30 days.
• Documentation of the following is required for treatment of migraine:
  • appropriate diagnosis; and
  • one of the following:
    • inadequate response, adverse reaction, or contraindication to sumatriptan tablets; or
    • member has nausea and vomiting with migraines, is unable to take oral medications, and prescriber provides medical records documenting an inadequate response or adverse reaction to sumatriptan nasal spray; or
    • medical records documenting an inadequate response or adverse reaction to ketorolac injection or ketorolac tablet; and
  • requested quantity is ≤ five bottles/30 days.

Licart

• Documentation of the following is required:
  • diagnosis of acute pain (caused by minor strains, sprains, and contusions) or osteoarthritis; and
  • inadequate response or adverse reaction to both of the following: diclofenac 1% gel, diclofenac topical patch (generic Flector).

meloxicam capsule

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to meloxicam tablet; and
  • inadequate response or adverse reaction to two other different NSAIDs; and
  • requested quantity is ≤ one unit/day.

naproxen/esomeprazole for members < 60 years of age

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical records documenting an inadequate response or adverse reaction with concurrent therapy of naproxen (minimum of 375 mg twice daily) and omeprazole (minimum of 20 mg twice daily).  

Relafen DS

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical records documenting an inadequate response or adverse reaction to an equivalent dose of nabumetone 500 mg or 750 mg; and
  • inadequate response or adverse reaction to two other different NSAIDs.

^†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.