FDA-approved, for example:

• Ocular infections involving the conjunctiva and/or cornea
  • bacterial conjunctivitis
  • bacterial keratitis/corneal ulcers
  • blepharitis/blepharoconjunctivitis
  • surgical prophylaxis

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 the member’s condition and requested medication (see below).

moxifloxacin ophthalmic solution

Documentation of the following is required:

• an appropriate diagnosis; and
• an inadequate response or adverse reaction to moxifloxacin ophthalmic solution (Vigamox).

SmartPA: Claims for moxifloxacin ophthalmic solution will usually process at the pharmacy without a PA request if the prescriber is an ophthalmologist.^†

Single-entity agents: Azasite, bacitracin ophthalmic ointment, gatifloxacin ophthalmic solution, and levofloxacin ophthalmic solution 

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • an inadequate response or adverse reaction to one or contraindication to all single-entity or combination ophthalmic antibiotic(s) agents not requiring prior authorization.

SmartPA: Claims for gatifloxacin ophthalmic solution and levofloxacin ophthalmic solution will usually process at the pharmacy without a PA request if the prescriber is an ophthalmologist.^†

Combination antibiotic/corticosteroid agents: Blephamide ointment, neomycin/polymyxin B/hydrocortisone ophthalmic suspension, Pred-G ointment, and Zylet

• Documentation of the following is required:
  • appropriate diagnosis; and
  • an inadequate response, adverse reaction, or contraindication to one of the following:
    • an ophthalmic antibiotic/corticosteroid combination agent available without prior authorization; or
    • a single-entity or combination ophthalmic antibiotic(s) and single-entity ophthalmic corticosteroid agent available without prior authorization.

Combination antibiotic/corticosteroid agent: Tobradex ST

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • an inadequate response, adverse reaction, or contraindication to at least one combination ophthalmic antibiotic/corticosteroid agent or a single-entity or combination ophthalmic antibiotic(s) and single-entity ophthalmic corticosteroid agent available without prior authorization; and
  • an inadequate response, adverse reaction, or contraindication to combination tobramycin 0.3%/dexamethasone 0.1% ophthalmic suspension or ointment.