FDA-approved, for example:

• Neurogenic detrusor overactivity
• Nocturia due to nocturnal polyuria in adults who awaken at least two times per night to void
• Overactive bladder with symptoms of urinary frequency, urgency, or incontinence

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.
• 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).

darifenacin, Gemtesa, and trospium extended-release

• Documentation of all of the following is required:
  • appropriate diagnosis; and 
  • an inadequate response or adverse reaction to two of the following, or contraindication to all of the following: Myrbetriq, oxybutynin extended-release tablet, solifenacin, tolterodine extended-release, Toviaz; and
  • quantity requested is for ≤ one unit/day.

SmartPA: Claims for darifenacin, Gemtesa, and trospium extended-release for a quantity of ≤ one unit/day will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims in the past 365 days for two of the following: Myrbetriq, oxybutynin extended-release tablet, solifenacin, tolterodine extended-release, Toviaz. ^†

Nocdurna

• Documentation of all of the following is required:
  • appropriate diagnosis; and 
  • member is ≥ 18 years of age; and  
  • one of the following:
    • an inadequate response or adverse reaction to desmopressin acetate tablets; or
    • clinical rationale why desmopressin acetate tablets may not be appropriate; and
  • appropriate dosing; and
  • quantity requested is for ≤ one unit/day.

SmartPA: Claims for Nocdurna for a quantity of ≤ one unit/day will usually process at the pharmacy without a PA request if the member is ≥ 18 years of age and has a history of paid MassHealth pharmacy claims in the past 365 days for desmopressin tablets. ^†

Vesicare LS

• Documentation of all of the following is required:
  • appropriate diagnosis; and 
  • prescriber is a urologist or consult notes from a urology office are provided; and  
  • one of the following:
    • member is ≥ two years of age and < five years of age; or
    • an inadequate response, adverse reaction, or contraindication to oxybutynin syrup; and
  • appropriate dosing.

^† 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.