Table 59: Anesthetics - Topical
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Drug Category: Dermatological Agents
Medication Class/Individual Agents: Local Anesthetics
I. Prior-Authorization Requirements
Topical Anesthetics |
Clinical Notes |
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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.
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Topical Anesthetics – Ophthalmic Topical Anesthetics |
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| # | This designates a brand-name drug with FDA “A”-rated generic equivalents. PA is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent. |
| MB | This drug is available through the health care professional who administers the drug or in an outpatient or inpatient hospital setting. MassHealth does not pay for this drug to be dispensed through the retail pharmacy. If listed, PA does not apply through the hospital outpatient and inpatient settings. Please refer to 130 CMR 433.408 for PA requirements for other health care professionals. Notwithstanding the above, this drug may be an exception to the unified pharmacy policy; please refer to respective MassHealth Accountable Care Partnership Plans (ACPPs) and Managed Care Organizations (MCOs) for PA status and criteria, if applicable. |
| A90 | Allowable 90-day supply. Dispensing in up to a 90-day supply is allowed. May not include all strengths or formulations. Quantity limits and other restrictions may apply. |
II. Therapeutic Uses
FDA-approved, for example:
- Dermatological procedure requiring local analgesia (lidocaine/prilocaine, Synera)
- Ocular surface anesthesia (Iheezo)
- Pain associated with diabetic peripheral neuropathy (Qutenza)
- Pain associated with post-herpetic neuralgia (lidocaine patch, Qutenza, Ztlido)
- Surface anesthesia and temporary pain relief (lidocaine ointment)
Note: The above list may not include all FDA-approved indications.
III. Evaluation Criteria for Approval
- 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.
Iheezo
- Documentation of all the following is required:
- appropriate diagnosis; and
- prescriber is an ophthalmologist or consult notes from an ophthalmologist are provided; and
- inadequate response or adverse reaction to one, or contraindication to all of the following: Akten, fluorescein/benoxinate, proparacaine, tetracaine.
lidocaine 5% patch > three patches/day
- Documentation of all the following is required:
- appropriate diagnosis; and
- medical necessity for > three patches/day.
lidocaine 5 % ointment, lidocaine/prilocaine
- Available without PA. However, requests for members with a diagnosis code for premature ejaculation will deny at the pharmacy as PA required.
- Please note: The MassHealth agency does not pay for any drug when used for the treatment of sexual dysfunction as described in 130 CMR 406.413(B) “Limitations on Coverage of Drugs – Drug Exclusions” (see link below).
https://www.mass.gov/regulations/130-CMR-406000-pharmacy-services
Qutenza for diabetic peripheral neuropathy
- Documentation of all the following is required:
- appropriate diagnosis; and
- inadequate response, adverse reaction, or contraindication to both of the following: topical capsaicin agent, lidocaine patch; and
- one of the following:
- medical necessity for transdermal formulation as noted by one of the following:
- 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; or
- inadequate response, adverse reaction, or contraindication to all of the following classes of oral agents:
- tricyclic antidepressant; and
- anticonvulsant (gabapentin at a dose of at least 1,200 mg/day for two weeks, or pregabalin); and
- venlafaxine or duloxetine.
- medical necessity for transdermal formulation as noted by one of the following:
Qutenza for post-herpetic neuralgia
- Documentation of all the following is required:
- appropriate diagnosis; and
- inadequate response, adverse reaction, or contraindication to both of the following: topical capsaicin agent, lidocaine patch; and
- one of the following:
- medical necessity for transdermal formulation as noted by one of the following:
- 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; or
- inadequate response, adverse reaction, or contraindication to both of the following classes of oral agents:
- tricyclic antidepressant; and
- anticonvulsant (gabapentin at a dose of at least 1,200 mg/day for two weeks, or pregabalin).
- medical necessity for transdermal formulation as noted by one of the following:
Synera
- Documentation of all the following is required:
- diagnosis of a procedure requiring local analgesia; and
- medical necessity for > four patches/30 days.
SmartPA: Claims for Synera (lidocaine/tetracaine) for > four patches/30 days and ≤ 12 patches/30 days will usually process at the pharmacy without a PA request if the member has a history of MassHealth medical claims for a diagnosis code for end-stage renal disease requiring dialysis.†
Ztlido
- Documentation of all the following is required:
- appropriate diagnosis; and
- inadequate response, adverse reaction, or contraindication to 5% lidocaine patch; and
- one of the following:
- requested quantity is ≤ three patches/day; or
- medical necessity for > three patches/day.
† 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.
Original Effective Date: 03/2012
Last Revised Date: 03/2024
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Last updated 04/01/24