FDA-approved, for example:

• Onychomycosis – Jublia and tavaborole
• Seborrheic dermatitis – ciclopirox and ketoconazole
• Superficial tinea or candida (fungal) infections
• Vulvovaginal candidiasis – vaginal formulations only

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.

ciclopirox 0.77% gel

• Documentation of all of the following is required for a diagnosis of seborrheic dermatitis of the scalp:
  • appropriate diagnosis; and
  • inadequate response (within the last 90 days), adverse reaction, or contraindication to both of the following: 
    • ciclopirox 1% shampoo; and
    • ketoconazole shampoo.

• Documentation of all of the following is required for a diagnosis of tinea corporis or tinea pedis:
  • appropriate diagnosis; and
  • inadequate response (within the last 90 days), adverse reaction, or contraindication to ciclopirox 0.77% cream; and
  • inadequate response (within the last 90 days) or adverse reaction to one or contraindication to all of the following available without PA: 
    • topical allylamine (e.g., terbinafine, tolnaftate); or
    • topical azole antifungal (e.g., clotrimazole, econazole, ketoconazole, miconazole); or
    • topical butenafine.

ciclopirox 1% shampoo 

• Documentation of all of the following is required:
  • diagnosis of one of the following: 
    • seborrheic dermatitis of the scalp; or
    • tinea capitis; and
  • inadequate response (within the last 90 days), adverse reaction, or contraindication to ketoconazole shampoo.

SmartPA: Claims for ciclopirox 1% shampoo will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for ketoconazole shampoo within the last 90 days.^†

ciclopirox 0.77% suspension

• Documentation of all of the following is required:
  • diagnosis of one of the following: 
    • cutaneous candidiasis; or
    • tinea corporis; or
    • tinea cruris; or
    • tinea pedis; or
    • tinea versicolor; and
  • inadequate response (within the last 90 days), adverse reaction, or contraindication to ciclopirox 0.77% cream.

SmartPA: Claims for ciclopirox 0.77% suspension will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for ciclopirox 0.77% cream within the last 90 days.^†

clotrimazole/betamethasone lotion

• Documentation of all of the following is required:
  • diagnosis of one of the following: 
    • tinea corporis; or
    • tinea cruris; or
    • tinea pedis; and
  • inadequate response (within the last 90 days), adverse reaction, or contraindication to clotrimazole/betamethasone cream.

SmartPA: Claims for clotrimazole/betamethasone lotion will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for clotrimazole/betamethasone cream within the last 90 days.^†

Jublia, tavaborole

• Documentation of the following is required:                              
  • appropriate diagnosis; and
  • one of the following:
    • inadequate response or adverse reaction to itraconazole or terbinafine oral tablets; or
    • medical necessity for topical formulation and inadequate response to 24 consecutive weeks of therapy or adverse reaction to ciclopirox nail solution; or
    • contraindication to all of the following: ciclopirox nail solution, itraconazole oral therapy and terbinafine oral tablets; and
  • for tavaborole, medical records documenting inadequate response to 48 weeks of therapy, adverse reaction, or contraindication to Jublia.  

ketoconazole foam

• Documentation of all of the following is required for a diagnosis of seborrheic dermatitis of the scalp:
  • appropriate diagnosis; and
  • member is ≥ 12 years of age; and 
  • inadequate response (within the last 90 days) or adverse reaction to one or contraindication to both of the following: 
    • ciclopirox gel; or
    • ciclopirox shampoo; and
  • inadequate response (within the last 90 days), adverse reaction, or contraindication to ketoconazole shampoo.
• Documentation of all of the following is required for a diagnosis of non-scalp seborrheic dermatitis:
  • appropriate diagnosis; and
  • inadequate response (within the last 90 days), adverse reaction, or contraindication to both of the following: 
    • one topical azole antifungal available without PA; or
    • ciclopirox cream.

luliconazole, naftifine cream, Naftin 1% gel, oxiconazole

• Documentation of all of the following is required:
  • diagnosis of one of the following:
    • tinea corporis; or
    • tinea cruris; or
    • tinea pedis; and
  • inadequate response (within the last 90 days) or adverse reaction to two or contraindication to all of the following available without PA:
    • topical allylamine (e.g., terbinafine, tolnaftate); or
    • topical azole antifungal (e.g., clotrimazole, econazole, ketoconazole, miconazole); or
    • topical butenafine; or
    • topical ciclopirox.

SmartPA: Claims for luliconazole, naftifine cream, Naftin 1% gel, and oxiconazole will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for two of the following available without PA within the last 90 days: topical allylamine (e.g., terbinafine, tolnaftate), topical azole antifungal (e.g., clotrimazole, econazole, ketoconazole, miconazole), topical butenafine, topical ciclopirox.^†

naftifine 2% gel

• Documentation of all of the following is required:
  • diagnosis of interdigital tinea pedis infection; and
  • inadequate response (within the last 90 days) or adverse reaction to two or contraindication to all of the following available without PA:
    • topical allylamine (e.g., terbinafine, tolnaftate); or
    • topical azole antifungal (e.g., clotrimazole, econazole, ketoconazole, miconazole); or
    • topical butenafine; or
    • topical ciclopirox.

SmartPA: Claims for naftifine 2% gel will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for two of the following available without PA within the last 90 days: topical allylamine (e.g., terbinafine, tolnaftate), topical azole antifungal (e.g., clotrimazole, econazole, ketoconazole, miconazole), topical butenafine, topical ciclopirox.^†

tolnaftate liquid

• Documentation of the following is required:                              
  • diagnosis of one of the following:
    • tinea corporis; or
    • tinea cruris; or
    • tinea pedis; and
  • inadequate response (within the last 90 days) or adverse reaction to two or contraindication to all of the following available without PA: 
    • topical azole antifungal (e.g., clotrimazole, econazole, ketoconazole, miconazole); or
    • topical butenafine; or
    • topical ciclopirox; and
  • inadequate response (within the last 90 days), adverse reaction, or contraindication to tolnaftate powder.  

SmartPA: Claims for tolnaftate liquid will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for tolnaftate powder and two of the following available without PA within the last 90 days: topical azole antifungal (e.g., clotrimazole, econazole, ketoconazole, miconazole), topical butenafine, topical ciclopirox.^†

^†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.