FDA-approved, for example:

• acute treatment of migraine (all triptans, dihydroergotamine injection, dihydroergotamine nasal spray, ergotamine/caffeine tablet, ergotamine/caffeine suppository, Nurtec, Reyvow, Trudhesa, Ubrelvy, Zavzpret)
• cluster headache (dihydroergotamine injection, sumatriptan injection)
• chronic tension-type headache (butalbital agents)
• episodic cluster headache (Emgality)
• migraine prophylaxis (Aimovig, Ajovy, Emgality, Nurtec, Qulipta, Vyepti)
• vascular headache (ergotamine/caffeine tablet, ergotamine/caffeine suppository)

Triptans are NOT intended for prophylactic therapy of migraines.

Non-FDA-approved, for example:

• cluster headache (all triptans except sumatriptan injection, dihydroergotamine nasal spray, ergotamine/caffeine tablet, ergotamine/caffeine suppository, Reyvow, Trudhesa)
• cyclic vomiting syndrome (sumatriptan 5 mg, 20 mg nasal spray, sumatriptan injection)
• migraine headache (butalbital agents)
• vascular headache (all triptans, dihydroergotamine injection, dihydroergotamine nasal spray, Reyvow, Trudhesa)

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.

Aimovig, Ajovy, Emgality

• Documentation of all of the following is required for migraine prophylaxis:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • appropriate dosing; and
  • migraine frequency ≥ four days per month; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: atenolol, metoprolol, nadolol, propranolol, timolol; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: topiramate,  tricyclic antidepressant, valproic acid, venlafaxine; and 
  • for Aimovig, inadequate response or adverse reaction to one or contraindication to all of the following: Ajovy, Emgality.

• Documentation of the following is required for Emgality for cluster headache:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • appropriate dosing.

• Documentation of the following is required for recertification of Emgality for cluster headache:
  • the member is still actively having a cluster headache; and
  • the member has been initiated on prophylactic therapy for the cluster headache; or
  • clinical rationale why prophylactic therapy is not appropriate.

almotriptan ( ≤ 18 units/30 days), eletriptan ( ≤ 18 units/30 days), and frovatriptan ( ≤ 18 units/30 days)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • one of the following:
    • for almotriptan, member is ≥ 12 years of age; or
    • for eletriptan or frovatriptan, member is ≥ 18 years of age; and
  • inadequate response or adverse reaction to two or contraindication to all of the following: rizatriptan tablets or orally disintegrating tablets (ODTs), sumatriptan tablets, zolmitriptan tablets.

SmartPA: Claims for ≤ 18 units/30 days of almotriptan tablets will usually process at the pharmacy without a PA request if there is a history of paid MassHealth pharmacy claims for at least two different oral triptan agents available without PA within quantity limits (sumatriptan tablets, rizatriptan ODTs or tablets, zolmitriptan tablets) and the member is ≥ 12 years of age.^†

SmartPA: Claims for ≤ 18 units/30 days of eletriptan or frovatriptan, will usually process at the pharmacy without a PA request if there is a history of paid MassHealth pharmacy claims for at least two different oral triptan agents available without PA within quantity limits (naratriptan, sumatriptan tablets, rizatriptan ODTs or tablets, zolmitriptan tablets) and the member is ≥ 18 years of age.^†

almotriptan ( > 18 units/30 days), eletriptan ( > 18 units/30 days), and frovatriptan ( > 18 units/30 days)

• For all requests, individual drug PA criteria must be met first where applicable.
• Requests will be evaluated on a case-by-case basis, taking into account the member's headache frequency, documentation of neurologist consultation, and prophylactic regimen.

Brand name Imitrex 5 mg, 20 mg nasal spray, Imitrex tablet, Maxalt MLT and tablet, and Zomig tablet ( ≤ 18 units/30 days)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical records documenting an inadequate response or adverse reaction to the generic equivalent of the requested agent; and
  • inadequate response or adverse reaction to all other triptans available without PA.

Brand name Imitrex 5 mg, 20 mg nasal spray, Imitrex tablet, Maxalt MLT and tablet, and Zomig tablet ( > 18 units/30 days)

• For all requests, individual drug PA criteria must be met first where applicable.
• Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

butalbital/acetaminophen/caffeine solution ( ≤ ten mL/day)

Please refer to additional criteria if request is for members < 18 years of age and/or for quantities exceeding ten mL/day.

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical condition in which member is not able to swallow solid oral dosage formulations; or
  • clinical rationale why conventional dosage formulations cannot be used.

butalbital/aspirin/caffeine capsule and butalbital 50 mg/acetaminophen 325 mg/caffeine 40 mg capsule ( ≤ 20 units/30 days)

Please refer to additional criteria if request is for members < 18 years of age and/or for quantities exceeding 20 units/30 days.

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to butalbital 50 mg/acetaminophen 325 mg/caffeine 40 mg tablets.

butalbital-containing agents (formulations that require PA for all quantities, excluding solution formulations and butalbital/aspirin/caffeine capsule) ( ≤ 20 units/30 days)  

Please refer to additional criteria if request is for members < 18 years of age and/or for quantities exceeding 20 units/30 days.

• Documentation of the following is required:
  • appropriate diagnosis; and
  • clinical rationale for the requested formulation instead of formulations available without PA within quantity limits.

butalbital-containing agents exceeding quantity limits ( > 20 units/30 days or > ten mL/day)

For all requests, individual drug PA criteria must be met first where applicable.

• Documentation of the following is required for a diagnosis of tension headache:
  • appropriate diagnosis; and
  • headache frequency; and
  • current prophylactic regimen; and
  • prescriber is a neurologist or neurology consult notes are provided; and
  • inadequate response or adverse reaction to three or contraindication to all of the following: NSAIDs, acetaminophen, aspirin, acetaminophen/caffeine, and acetaminophen/aspirin/caffeine.

• Documentation of the following is required for a diagnosis of migraine headache:
  • appropriate diagnosis; and
  • headache frequency; and
  • current prophylactic regimen; and
  • prescriber is a neurologist or neurology consult notes are provided; and
  • inadequate response or adverse reaction to two or contraindication to all triptans; and
  • inadequate response or adverse reaction to two or contraindication to all of the following: NSAIDs, acetaminophen, aspirin, acetaminophen/caffeine, acetaminophen/aspirin/caffeine, and ergot alkaloid; and
  • inadequate response or adverse reaction to one or contraindication to all oral CGRP inhibitors.

butalbital-containing agents for members < 18 years of age 

For all requests, individual drug PA criteria must be met first where applicable.

• Documentation of the following is required for a diagnosis of tension headache:
  • appropriate diagnosis; and
  • headache frequency; and
  • current prophylactic regimen if member experiences more than four headaches per month or headaches that last longer than 12 hours; and
  • prescriber is a neurologist or neurology consult notes are provided that support the use of a butalbital-containing agent; and
  • inadequate response, adverse reaction, or contraindication to all of the following: NSAIDs, acetaminophen, aspirin, acetaminophen/caffeine, acetaminophen/aspirin/caffeine.

• Documentation of the following is required for a diagnosis of migraine headache:
  • appropriate diagnosis; and
  • headache frequency; and
  • current prophylactic regimen if member experiences more than four headaches per month or headaches that last longer than 12 hours; and
  • prescriber is a neurologist or consult notes from a neurologist are provided that support the use of a butalbital-containing agent; and
  • inadequate response or adverse reaction to two or contraindication to all triptans; and
  • inadequate response, adverse reaction, or contraindication to all of the following: NSAIDs, acetaminophen, aspirin, acetaminophen/caffeine, acetaminophen/aspirin/caffeine. 

codeine-containing products for members < 12 years of age

For all requests, individual drug PA criteria and/or butalbital-containing agents age restriction criteria must be met first where applicable.

• Documentation of one of the following is required:
  • CYP2D6 genotyping confirms member is not an ultra-rapid CYP2D6 metabolizer; or 
  • member has previously utilized a codeine-containing product without adverse effect that prevents repeat use. 

dihydroergotamine injection

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical necessity for the requested formulation as noted by one of the following:
    • cluster headache; or
    • nausea or vomiting with migraine; and
  • inadequate response, adverse reaction, or contraindication to sumatriptan injection.

dihydroergotamine nasal spray (generic Migranal) and Trudhesa ( ≤ eight units/30 days)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to both of the following: sumatriptan nasal spray, zolmitriptan nasal spray.

dihydroergotamine nasal spray (generic Migranal) and Trudhesa ( > eight units/30 days)

• Documentation of the following is required:
  • for all requests, individual drug PA criteria must be met first where applicable; and
  • headache frequency; and
  • neurology consultation should be provided if headache frequency is > 15 headaches/30 days; and
  • member is currently on a prophylactic regimen.

ergotamine/caffeine tablet

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to both of the following: rizatriptan ODT or tablets, sumatriptan tablets; and
  • requested quantity is ≤ 40 tablets/30 days.

ergotamine/caffeine suppository

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical necessity for the requested formulation as noted by nausea or vomiting with migraine; and
  • inadequate response, adverse reaction, or contraindication to sumatriptan nasal spray; and
  • requested quantity is ≤ 18 suppositories/30 days.

naratriptan, rizatriptan ODT and tablet, sumatriptan 5 mg, 20 mg nasal spray, sumatriptan tablet, and zolmitriptan tablet ( > 18 units/30 days)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • for sumatriptan 5 mg, 20 mg nasal spray, member is ≥ 6 years of age; and
  • requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

Nurtec

• Documentation of the following is required for a diagnosis of acute treatment of migraine:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse drug reaction to two or contraindication to all oral triptans; and
  • requested quantity is ≤ 16 units/30 days.

• Documentation of all of the following is required for a diagnosis of migraine prophylaxis:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • migraine frequency ≥ four days per month; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: Aimovig, Ajovy, Emgality; and
  • requested quantity is ≤ 16 units/30 days.

Ubrelvy ( ≤ 16 units/30 days)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse drug reaction to two or contraindication to all oral triptans.

Nurtec and Ubrelvy ( > 16 units/30 days)

• For all requests, individual drug PA criteria must be met first where applicable.
• Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency and prophylactic regimen.

Qulipta

• Documentation of all of the following is required for a diagnosis of migraine prophylaxis:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • migraine frequency ≥ four days per month; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: atenolol, metoprolol, nadolol, propranolol, timolol; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: Botox, topiramate, tricyclic antidepressant, valproic acid, venlafaxine; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: Aimovig, Ajovy, Emgality; and
  • requested quantity is ≤ one unit/day.

Reyvow ( ≤ eight units/30 days)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse reaction to two different triptan agents or contraindication to all oral triptans; and
  • prescriber is a neurologist or consult from a neurologist is provided. 

Reyvow ( > eight units/30 days)

• For all requests, individual drug PA criteria must be met first where applicable.
• Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

sumatriptan injection ( ≤ 18 injections/30 days)

• Documentation of the following is required for a diagnosis of acute treatment of migraine, cluster headache, vascular headache:
  • appropriate diagnosis; and
  • medical necessity for the requested formulation as noted by one of the following:
    • cluster headache; or
    • nausea or vomiting with migraine.

• Documentation of the following is required for a diagnosis of acute treatment of cyclic vomiting syndrome:
  • appropriate diagnosis.

sumatriptan injection ( > 18 injections/30 days) and zolmitriptan nasal spray ( > 18 units/30 days)

• For all requests, individual drug PA criteria must be met first where applicable.
• Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

sumatriptan/naproxen ( ≤ 18 units/30 days)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to two of the following: sumatriptan tablets, rizatriptan ODT or tablets, and zolmitriptan tablets; and
  • medical necessity for the combination product instead of the commercially available separate agents.

sumatriptan/naproxen ( > 18 units/30 days)

• For all requests, individual drug PA criteria must be met first where applicable.
• Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

Tosymra ( ≤ 18 units/30 days)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical necessity for the requested formulation as noted by nausea or vomiting with migraine; and
  • inadequate response or adverse reaction to one or contraindication to both of the following:
    • sumatriptan 5 mg or 20 mg nasal spray; or
    • zolmitriptan nasal spray.

Tosymra ( > 18 units/30 days)

• For all requests, individual drug PA criteria must be met first where applicable.
• Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

Vyepti

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • appropriate dosing; and
  • migraine frequency ≥ four days per month; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: atenolol, metoprolol, nadolol, propranolol, timolol; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: Botox, topiramate, tricyclic antidepressant, valproic acid, venlafaxine;  and
  • inadequate response or adverse reaction to one or contraindication to all of the following: Aimovig, Ajovy, Emgality.

Zavzpret ( ≤ 12 units/30 days)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response or adverse reaction to two or contraindication to all triptan nasal sprays; and
  • medical necessity for the requested formulation as noted by nausea or vomiting with migraine.

Zavzpret ( > 12 units/30 days)

• For all requests, individual drug PA criteria must be met first where applicable.
• Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

Zembrace ( ≤ 36 units/30 days)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical necessity for the requested formulation as noted by nausea or vomiting with migraine; and
  • inadequate response or adverse reaction to sumatriptan injection (generic Imitrex).

Zembrace ( > 36 units/30 days)

• For all requests, individual drug PA criteria must be met first where applicable.
• Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

zolmitriptan ODT ( ≤ 18 units/30 days)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to two of the following: rizatriptan ODT or tablets, sumatriptan tablets, and zolmitriptan tablets; or
  • both of the following:
    • medical necessity for the requested formulation as noted by nausea or vomiting with migraine; and 
    • inadequate response or adverse reaction to rizatriptan ODT.

zolmitriptan ODT ( > 18 units/30 days)

• For all requests, individual drug PA criteria must be met first where applicable.
• Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

zolmitriptan nasal spray ( < 18 units/30 days)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical necessity for the requested formulation as noted by nausea or vomiting with migraine.

 ^†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.