FDA-approved, for example:

• chorea associated with Huntington’s disease
• tardive dyskinesia

Non-FDA-approved, for example:

• tardive dyskinesia (tetrabenazine)
• Tourette’s syndrome/tics (Austedo, Austedo XR, Ingrezza, tetrabenazine)
• unspecified hyperkinetic movement disorder (Austedo, Austedo XR, Ingrezza, tetrabenazine)

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.

Austedo and Austedo XR

• Documentation of all of the following is required for a diagnosis of Huntington’s disease:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse reaction to tetrabenazine; and
  • one of the following:
    • requested dose is ≤ 36 mg/day; or
    • requested dose is > 36 mg/day and ≤ 48 mg/day, and member has been genotyped for the drug metabolizing enzyme CYP2D6 to determine that the member is not a poor metabolizer; and
  • one of the following:
  • for Austedo, requested quantity is ≤ four units/day; or
  • for Austedo XR 6 mg or 12 mg, requested quantity is ≤ three units/day; or
  • for Austedo XR 24 mg, requested quantity is ≤ two units/day.

• Documentation of all of the following is required for a diagnosis of tardive dyskinesia:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • persistent, disabling, or intrusive tardive dyskinesia; and
  • one of the following:
    • requested dose is ≤ 36 mg/day; or
    • requested dose is > 36 mg/day and ≤ 48 mg/day, and member has been genotyped for the drug metabolizing enzyme CYP2D6 to determine that the member is not a poor metabolizer; and
    • one of the following:
    • for Austedo, requested quantity is ≤ four units/day; or
    • for Austedo XR 6 mg or 12 mg, requested quantity is ≤ three units/day; or
    • for Austedo XR 24 mg, requested quantity is ≤ two units/day.

• Documentation of all of the following is required for a diagnosis of Tourette’s syndrome/tics:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse reaction to two or contraindication to all of the following: baclofen, botulinum toxin, clonidine or guanfacine, first or second generation antipsychotic, topiramate or levetiracetam; and
  • inadequate response or adverse reaction to tetrabenazine; and
  • one of the following:
    • requested dose is < 36 mg/day; or
    • requested dose is > 36 mg/day and < 48 mg/day and member has been genotyped for the drug metabolizing enzyme CYP2D6 to determine that the member is not a poor metabolizer; and
    • one of the following:
    • for Austedo, requested quantity is ≤ four units/day; or
    • for Austedo XR 6 mg or 12 mg, requested quantity is ≤ three units/day; or
    • for Austedo XR 24 mg, requested quantity is ≤ two units/day. 

• Documentation of all of the following is required for a diagnosis of unspecified hyperkinetic movement disorder:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse reaction to two or contraindication to all of the following: baclofen, benzodiazepine, botulinum toxin, clonidine, levodopa/carbidopa, trihexyphenidyl; and
  • inadequate response or adverse reaction to tetrabenazine; and
  • one of the following:
    • requested dose is < 36 mg/day; or
    • requested dose is > 36 mg/day and < 48 mg/day and member has been genotyped for the drug metabolizing enzyme CYP2D6 to determine that the member is not a poor metabolizer; and
  • one of the following:
    • for Austedo, requested quantity is ≤ four units/day; or
    • for Austedo XR 6 mg or 12 mg, requested quantity is ≤ three units/day; or
    • for Austedo XR 24 mg, requested quantity is ≤ two units/day.

Ingrezza

• Documentation of all of the following is required for a diagnosis of Huntington's Disease:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse reaction to tetrabenazine; and
  • requested quantity is ≤ one unit/day.

• Documentation of all of the following is required for a diagnosis of tardive dyskinesia:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • persistent, disabling, or intrusive tardive dyskinesia; and
  • requested quantity is ≤ one unit/day.

• Documentation of all of the following is required for a diagnosis of unspecified Tourette’s syndrome/tics:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse reaction to two or contraindication to all of the following: baclofen, botulinum toxin, clonidine or guanfacine, first or second generation antipsychotic, topiramate or levetiracetam, and
  • inadequate response or adverse reaction to tetrabenazine; and
  • requested quantity is ≤ one unit/day.

• Documentation of all of the following is required for a diagnosis of unspecified hyperkinetic movement disorder:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse reaction to two or contraindication to all of the following: baclofen, benzodiazepine, botulinum toxin, clonidine, levodopa/carbidopa, trihexyphenidyl, and
  • inadequate response or adverse reaction to tetrabenazine; and
  • requested quantity is ≤ one unit/day.

tetrabenazine

• Documentation of all of the following is required for a diagnosis of Huntington’s disease:
  • appropriate diagnosis; and
  • one of the following:
    • requested dose is ≤ 50 mg/day; or
    • requested dose is > 50 mg/day and ≤ 100 mg/day, and member has been genotyped for the drug metabolizing enzyme CYP2D6 to determine that the member is not a poor metabolizer.
  • member is ≥ 18 years of age.

• Documentation of all of the following is required for a diagnosis of tardive dyskinesia:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • persistent, disabling, or intrusive tardive dyskinesia; and
  • requested dose is ≤ 200 mg/day.

• Documentation of all of the following is required for a diagnosis of Tourette’s syndrome/tics:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse reaction to two or contraindication to all of the following: baclofen, botulinum toxin, clonidine or guanfacine, first or second generation antipsychotic, topiramate or levetiracetam; and
  • requested dose is ≤ 75 mg/day.

• Documentation of all of the following is required for a diagnosis of unspecified hyperkinetic movement disorder:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse reaction to two or contraindication to all of the following: baclofen, benzodiazepine, botulinum toxin, clonidine, levodopa/carbidopa, trihexyphenidyl; and
  • requested dose is ≤ 200 mg/day.

SmartPA: Claims for tetrabenazine at a dose of ≤ 100 mg/day will usually process at the pharmacy without a PA request if the member is ≥ 18 years of age, has a history of MassHealth medical claims for Huntington’s disease with chorea, and has a history of paid MassHealth pharmacy claims for tetrabenazine for at least 90 out of the last 120 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.