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Table 69: Barbiturates, Benzodiazepines, and Miscellaneous Antianxiety Agents


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: Central Nervous System

Medication Class/Individual Agents: Barbiturates, Benzodiazepines, and Miscellaneous Antianxiety Agents

I. Prior-Authorization Requirements

 Antianxiety Agents – Not Otherwise Classified

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

amitriptyline / chlordiazepoxide PA  
buspirone PA   - < 6 years A90
chlordiazepoxide / clidinium Librax PA  
meprobamate PA  

 Barbiturates

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

phenobarbital 100 mg vial Sezaby test   MB

      

 
phenobarbital tablet, solution, injection test  

 Benzodiazepines

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

alprazolam Xanax PA   - < 6 years #
  • Extended-release and orally disintegrating benzodiazepine formulations require prior authorization (PA) due to the availability of less-costly dosage formulations. 
  • For additional information regarding the management of benzodiazepine powders for compounding, please see: Table 79 - Pharmaceutical Compounds.
 
alprazolam extended-release Xanax XR PA   - < 6 years and PA > 2 units/day #
alprazolam orally disintegrating tablet PA  
chlordiazepoxide PA   - < 6 years
clonazepam 0.125 mg, 0.25 mg, 0.5 mg, 1 mg orally disintegrating tablet PA   - < 6 years and PA > 3 units/day
clonazepam 2 mg orally disintegrating tablet PA   - < 6 years and PA > 2 units/day
clonazepam tablet Klonopin PA   - < 6 years #
clorazepate PA  
diazepam injection test  
diazepam solution, tablet Valium PA   - < 6 years #
estazolam PA   - < 6 years and PA > 1 unit/day
flurazepam PA   - < 6 years and PA > 1 unit/day
lorazepam extended-release Loreev XR PA  
lorazepam injection Ativan test   #
lorazepam solution, tablet Ativan PA   - < 6 years #
midazolam injection test   MB
midazolam syrup PA   - < 6 years
oxazepam PA  
quazepam Doral PA  
remimazolam Byfavo PA   MB
temazepam 22.5 mg Restoril PA  
temazepam 7.5 mg, 15 mg, 30 mg Restoril PA   - < 6 years and PA > 1 unit/day #
triazolam Halcion PA   - < 6 years and PA > 1 unit/day #
Table Footnotes
# 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:

  • Alcohol withdrawal syndrome (alprazolam ER, clorazepate, oxazepam)
  • Anxiety, panic disorder, skeletal muscle spasm, or seizure (benzodiazepines excluding chlordiazepoxide/clidinium)
  • Anxiety (Loreev XR, meprobamate)
  • Emotional and somatic factors in gastrointestinal disorders (chlordiazepoxide/clidinium)
  • Adjunctive therapy in peptic ulcer, irritable bowel syndrome, and acute enterocolitis (chlordiazepoxide/clidinium)
  • Induction and maintenance of procedural sedation in adults undergoing procedures lasting 30 minutes or less (Byfavo)
  • Insomnia (estazolam, flurazepam, quazepam, temazepam, triazolam)
  • Seizure disorder (clorazepate, oxazepam)

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

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.

 

alprazolam extended-release > two units/day

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • requested dose cannot be consolidated; and
    • medical records documenting titration of medication up to current dose; and
    • clinical rationale for dosing higher than FDA approved limits. 

      

alprazolam orally disintegrating tablet

  • Documentation of all of the following is required:       
    • appropriate diagnosis; and
    • requested dose cannot be consolidated; and
    • medical necessity for an orally disintegrating tablet (ODT) formulation as indicated by both of the following:
      • member has a g-tube, dysphagia, or swallowing difficulties; and
      • member is currently not using other oral medications.

 

Byfavo

  • Documentation of all of the following is required:
    • the agent will be used for induction and maintenance of procedural sedation; and
    • inadequate response, adverse reaction, or contraindication to intravenous midazolam; and  
    • appropriate dosing.

      

chlordiazepoxide/amitriptyline

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the use of the combination product instead of the commercially available separate agents.

SmartPA: Claims for chlordiazepoxide/amitriptyline will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for the requested agent for at least 90 days of therapy out of the last 120 days.     

 

chlordiazepoxide/clidinium

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • requested quantity is ≤ eight units/day; and
    • prescriber is a gastrointestinal specialist or consult notes from a gastroenterology office are provided; and
    • inadequate response or adverse reaction to two or contraindication to all anticholinergic/antispasmodics; and
    • inadequate response or adverse reaction to one or contraindication to all SSRIs; and
    • inadequate response or adverse reaction to one or contraindication to all non-benzodiazepine anxiolytics; and
    • inadequate response or adverse reaction to one other benzodiazepine; and
    • requested medication will be used as an adjunctive therapy; and
    • for a diagnosis of peptic ulcer, all of the following:
      • inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to two proton pump inhibitors, or contraindication to all proton pump inhibitors; and
      • requested treatment duration is ≤ 12 weeks; and
      • for H. pylori-positive peptic ulcer, an inadequate response to one four-week course of appropriate combination therapy; or
    • for a diagnosis of irritable bowel syndrome with constipation, both of the following:
      • inadequate response or adverse reaction to two or contraindication to all of the following: Linzess, lubiprostone, Trulance; and
      • inadequate response, adverse reaction, or contraindication to one agent from three of the four traditional laxative therapy classes (bulk forming laxatives, osmotic laxatives, saline laxatives, stimulant laxatives); or
    • for a diagnosis of irritable bowel syndrome with diarrhea, inadequate response or adverse reaction to five or contraindication to all of the following: bile acid sequestrants, bismuth subsalicylate, bulk-forming laxatives, diphenoxylate/atropine, loperamide, Xifaxan; or
    • for a diagnosis of acute enterocolitis, all of the following:
      • inadequate response, adverse reaction, or contraindication to both of the following: bismuth subsalicylate, loperamide; and
      • requested treatment duration ≤ three days.

  

clonazepam 0.125 mg, 0.25 mg, 0.5 mg, and 1 mg orally disintegrating tablet > three units/day

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • prescriber is a neurologist or psychiatrist, or consult notes from a neurologist or psychiatrist are provided; and
    • requested dose cannot be consolidated within quantity limits; and
    • medical records documenting titration of medication up to current dose; and
    • clinical rationale for dosing higher than the FDA approved limits.

 

clonazepam 2 mg orally disintegrating tablet > two units/day

  • Documentation of all of the following is required:       
    • appropriate diagnosis; and
    • prescriber is a neurologist or psychiatrist, or consult notes from a neurologist or psychiatrist are provided; and
    • requested dose cannot be consolidated within the quantity limit; and
    • medical records documenting titration of medication up to current dose; and
    • clinical rationale for dosing higher than the FDA approved limits. 

 

clorazepate and oxazepam

  • Documentation of all of the following is required
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to two or contraindication to all benzodiazepines: alprazolam, chlordiazepoxide, clonazepam, diazepam, lorazepam.

SmartPA: Claims for clorazepate and oxazepam will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for at least 90 days of therapy out of the last 120 days. 


estazolam, flurazepam, temazepam 7.5 mg, 15 mg, and 30 mg, and triazolam 0.125 mg > one unit/day

  • Documentation of all of the following is required:
    • diagnosis of insomnia; and
    • requested dose cannot be consolidated; and
    • medical necessity for exceeding the quantity limit noted by all of the following:
      • inadequate response to the established quantity limit; and
      • higher dose was effective in alleviating symptoms; and
      • for requests exceeding the FDA-approved maximum dose, inadequate response or adverse reaction to two alternatives for sleep (one must be a non-benzodiazepine hypnotic):
        • non-benzodiazepine hypnotics: eszopiclone, zaleplon, zolpidem (IR or ER); or
        • other alternatives: Belsomra, Dayvigo, diphenhydramine, doxepin capsule, doxepin tablet, melatonin, Quvivq, Rozerem, trazodone.

 

Loreev XR

  • Documentation of all of the following is required
    • appropriate diagnosis; and
    • medical records documenting stability with lorazepam tablets in three evenly divided daily doses; and
    • one of the following:
      • medical records documenting inadequate response or adverse reaction to two intermediate/long- or long-acting benzodiazepines; or
      • contraindication to all other long-acting benzodiazepines; and
    • requested quantity is ≤ one unit/day.

 

meprobamate

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to two or contraindication to all benzodiazepines (Please note, up to two one-month provisional approvals may be allowed for members who are stabilized on the requested medication to avoid risk of withdrawal). 
  • For recertification requests, documentation of all of the following is required:
    • inadequate response (defined as ≥ 30 days of therapy) or adverse reaction to three or contraindication to all of the following: buspirone, SSRI, SNRI, TCA; and
    • clinical rationale for continued therapy with meprobamate.

 

quazepam

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response or adverse reaction to all of the following hypnotic benzodiazepines: estazolam, flurazepam, temazepam 7.5, 15, or 30 mg, triazolam.

 

temazepam 22.5 mg

  • Documentation of all of the following is required:       
    • appropriate diagnosis; and
    • medical records documenting an adverse reaction or inadequate response to all of the following hypnotic benzodiazepines:       
      • estazolam; and
      • flurazepam; and
      • temazepam 7.5 mg, 15 mg, or 30 mg; and
      • triazolam; and
    • one of the following:
      • requested quantity is ≤ one unit/day; or
      • all of the following
        • inadequate response to 30 mg/day; and
        • medical records documenting titration of medication up to current dose; and
        • clinical rationale for dosing higher than the FDA approved limits. 

 

triazolam 0.25 mg > one unit/day

  • Documentation of all of the following is required:
    • diagnosis of insomnia; and
    • inadequate response to 0.25 mg/day.

 

Brand-name products (Ativan, Klonopin, Xanax)

  • Documentation of all of the following is required:       
    • appropriate diagnosis; and
    • medical records documenting an adverse reaction or inadequate response to a generic equivalent of the requested product; and
    • inadequate response (defined as ≥ 30 days of therapy) or adverse reaction to one other non-hypnotic benzodiazepine; and
    • requested dose cannot be consolidated within the quantity limit.

 

Benzodiazepine Polypharmacy (overlapping pharmacy claims for two or more benzodiazepines [excludes clobazam, nasal and rectal diazepam, nasal midazolam, and injectable formulations] for at least 60 days within a 90-day period) 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 sleep diagnosis:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnosis; and
      • clear treatment plan (i.e., medication name(s), dose, frequency); and
      • severity of sleep diagnosis outlined; and
      • intended treatment duration and prescriber follow-up plan noted; and
      • one of the following:
        • cross-titration/taper of benzodiazepine therapy (Please note, six-month provisional approval may be allowed for members who are cross-titrating or tapering from one agent to another); or
        • both of the following:
          • inadequate response or adverse reaction to three or contraindication to all of the following (trials must include at least one non-benzodiazepine hypnotic): 
            • non-benzodiazepine hypnotics: eszopiclone, zaleplon, zolpidem (IR or ER); or
            • other alternatives: Belsomra, Dayvigo, diphenhydramine, doxepin capsule, doxepin tablet, melatonin, Quviviq, Rozerem, trazodone; and
          • the benzodiazepine regimen includes one short acting benzodiazepine agent and one long-acting benzodiazepine agent (Please note, up to two one-month provisional approvals may be allowed for members whose regimens include two short-acting or two long-acting benzodiazepine agents and all other criteria are met).

 

  • Documentation of the following is required for a psychiatric diagnosis:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following: 
      • appropriate diagnosis; and
      • clear treatment plan (i.e., diagnosis intended to treat, medication name(s), dose, frequency); and
      • severity of psychiatric condition outlined; and
      • intended treatment duration and prescriber follow-up plan noted; and
      • one of the following: 
        • cross-titration/taper of benzodiazepine therapy (Please note, six-month provisional approval may be allowed for members who are cross-titrating or tapering from one agent to another); or
        • both of the following:
          • inadequate response or adverse reaction to three (trials must include at least one SSRI and one SNRI, unless classes are contraindicated) or contraindication to all of the following: buspirone (for the diagnosis of GAD only), mirtazapine, SNRI, SSRI, TCA, Trintellix, vilazodone; and
          • the benzodiazepine regimen includes one short acting benzodiazepine agent and one long-acting benzodiazepine agent (Please note, up to two one-month provisional approvals may be allowed for members whose regimens include two short-acting or two long-acting benzodiazepine agents and all other criteria are met).

Please note, up to two one-month provisional approvals may be allowed for members who are stabilized on the requested medication(s) to avoid risk of destabilization.


  • Documentation of the following is required for a musculoskeletal diagnosis:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following: 
      • appropriate diagnosis; and
      • clear treatment plan (i.e., diagnosis intended to treat, medication name(s), dose, frequency); and
      • severity of musculoskeletal condition outlined; and
      • intended treatment duration and prescriber follow-up plan noted; and
      • one of the following: 
        • cross-titration/taper of benzodiazepine therapy (Please note, six-month provisional approval may be allowed for members who are cross-titrating or tapering from one agent to another); or
        • both of the following: 
          • inadequate response or adverse reaction to three or contraindication to all of the following skeletal muscle relaxants: chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine; and
          • the benzodiazepine regimen includes one short-acting benzodiazepine agent and one long-acting benzodiazepine agent (Please note, up to two one-month provisional approvals may be allowed for members whose regimens include two short-acting or two long-acting benzodiazepine agents and all other criteria are met).
Please note, up to two one-month provisional approvals may be allowed for members who are stabilized on the requested medication(s) to avoid risk of destabilization.
  • Documentation of the following is required for a seizure diagnosis:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following: 
      • appropriate diagnosis; and
      • clear treatment plan (i.e., diagnosis intended to treat, medication name(s), dose, frequency); and
      • intended treatment duration and prescriber follow-up plan noted; and
      • one of the following: 
        • stability on the requested regimen; or
        • cross-titration/taper of benzodiazepine therapy (Please note, six-month provisional approval may be allowed for members who are cross-titrating or tapering from one agent to another); or
        • both of the following:
          • inadequate response or adverse reaction to three anticonvulsants; and 
          • the benzodiazepine regimen includes one short-acting benzodiazepine agent and one long-acting benzodiazepine agent.
Please note, up to two one-month provisional approvals may be allowed for members who are stabilized on the requested medication(s) to avoid risk of destabilization.

  • Documentation of the following is required for both a seizure and psychiatric diagnosis: 
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following: 
      • appropriate diagnosis; and
      • clear treatment plan (i.e., diagnosis intended to treat, medication name(s), dose, frequency); and
      • intended treatment duration and prescriber follow-up plan noted; and
      • one of the following:
        • stability on the requested regimen; or
        • cross-titration/taper of benzodiazepine therapy (Please note, six-month provisional approval may be allowed for members who are cross-titrating or tapering from one agent to another); or
        • all of the following:
          • inadequate response or adverse reaction to three anticonvulsants; and
          • inadequate response or adverse reaction to three (trials must include at least one SSRI and one SNRI, unless classes are contraindicated) or contraindication to all of the following: buspirone (for the diagnosis of GAD only), mirtazapine, SNRI, SSRI, TCA, Trintellix, vilazodone; and
          • the benzodiazepine regimen includes one short-acting benzodiazepine agent and one long-acting benzodiazepine agent.
Please note, up to two one-month provisional approvals may be allowed for members who are stabilized on the requested medication(s) to avoid risk of destabilization.



Concomitant Opioid and Benzodiazepine Polypharmacy (pharmacy claims for ≥ 15 days supply for one or more opioid(s) [new to therapy] and one or more benzodiazepine(s) [clobazam, nasal and rectal diazepam, nasal midazolam, and injectable formulations are not included] for ≥ 15 days supply within the past 45-day period.)

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of all of the following is required:
    • individual drug PA criteria must be met first where applicable; and
    • appropriate diagnosis for the benzodiazepine; and
    • appropriate diagnosis for the opioid; and
    • one of the following:
      • member's treatment is currently managed by palliative care; or 
      • member is currently in hospice or is transitioning to hospice; or 
      • member is currently being treated for sickle cell disease or cancer pain; or
      • if the benzodiazepine is being used for a psychiatric diagnosis, an inadequate response (defined as ≥ 4 weeks of therapy), or adverse reaction to three antidepressants, or contraindication to all antidepressants; or
      • if the benzodiazepine is being used for a musculoskeletal diagnosis, an inadequate response, or adverse reaction to three skeletal muscle relaxants (e.g., cyclobenzaprine, chlorzoxazone, metaxalone, methocarbamol, orphenadrine), or a contraindication to all skeletal muscle relaxants; or
      • if the benzodiazepine is being used for a sleep disorder, an inadequate response, or adverse reaction to three non-benzodiazepine sleep medications, or a contraindication to all non-benzodiazepine sleep medications; or
      • if the benzodiazepine is being used for a seizure disorder, member is stable on a non-benzodiazepine anticonvulsant; or
      • treatment plan to taper off or taper down from benzodiazepine therapy; or
      • treatment plan to taper off opioid therapy; or
      • clinical rationale for the concomitant use of opioids and benzodiazepines; and
    • member will be co-prescribed naloxone.

   

In addition to individual drug PA criteria where applicable, some behavioral health medications are subject to additional polypharmacy and age limit restrictions.

 

Behavioral Health Medication Polypharmacy (pharmacy claims for any combination of four or more behavioral health medications [i.e., alpha2 agonists, antidepressants, antipsychotics, armodafinil, atomoxetine, benzodiazepines, buspirone, cerebral stimulants, donepezil, hypnotic agents, memantine, modafinil, mood stabilizers (agents considered to be used only for seizure diagnoses are not included), naltrexone, and viloxazine] within a 45-day period) for members < 18 years of age

  • For all requests, individual drug PA criteria must be met first where applicable.
  • For regimens including ≤ two mood stabilizers (also includes regimens that do not include a mood stabilizer), documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnoses; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided.
  • For regimens including ≥ three mood stabilizers, documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnoses; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; and
      • one of the following:
        • member has a seizure diagnosis only; or
        • member has an appropriate psychiatric diagnosis, with or without seizure diagnosis, and one of the following:
          • cross-titration/taper of mood stabilizer therapy; or
          • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate; or
        • member has a diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain), with or without seizure diagnosis, and that other clinically appropriate therapies have been tried and failed; therefore, multiple mood stabilizers are needed; or
        • member has psychiatric and comorbid diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain), with or without seizure diagnosis, and that other clinically relevant therapies have been tried and failed; therefore, multiple mood stabilizers are needed, and one of the following:
          • cross-titration/taper of mood stabilizer therapy; or
          • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate.

    

Benzodiazepine Polypharmacy (overlapping pharmacy claims for two or more benzodiazepines [hypnotic benzodiazepine agents, clobazam, nasal and rectal diazepam, nasal midazolam, and injectable formulations are not included] for at least 60 days within a 90-day period) 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:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
      • member has a seizure diagnosis only; or
    • all of the following:
      • appropriate diagnosis; and
      • treatment plan including names of current benzodiazepines and corresponding diagnoses; and
      • one of the following:
        • cross-titration/taper of benzodiazepine therapy; or
        • clinical rationale for use of ≥ two benzodiazepines of different chemical entities.

 

buspirone for members < six years of age

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnosis; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided.

 

Benzodiazepine (hypnotic benzodiazepine agents are not included) for members < six years of age

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
      • member has a seizure diagnosis only; or
    • all of the following: 
      • appropriate diagnosis; and
      • treatment plan including names of current behavioral health medications and corresponding indications; and
      • prescriber is a specialist (e.g. psychiatrist, neurologist) or consult is provided.

SmartPA: Claims for mood stabilizers or benzodiazepines will usually process at the pharmacy without a PA request if the member is < six years of age, has a history of MassHealth medical claims for seizure, and does not have a history of MassHealth medical claims for psychiatric diagnoses and/or other diagnoses in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain).

 

estazolam, flurazepam, temazepam 7.5 mg, 15 mg, and 30 mg, and triazolam for members < six years of age

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required for members with a diagnosis of insomnia with other behavioral health comorbidities, excluding ADHD:
    • treatment plan including name of current hypnotic agent and corresponding diagnosis; and
    • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided.

 

  • Documentation of the following is required for members with a diagnosis of insomnia without behavioral health comorbidities:
    • treatment plan including name of current hypnotic agent and corresponding diagnosis; and
    • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; and
    • inadequate response (defined by ≥ 10 days of therapy), adverse reaction, or contraindication to melatonin.

 

  • Documentation of the following is required for members with a diagnosis of insomnia with comorbid ADHD:
    • treatment plan including name of current hypnotic agent and corresponding diagnosis; and
    • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; and
    • inadequate response (defined by ≥ 10 days of therapy), adverse reaction, or contraindication to melatonin; and
    • inadequate response (defined by ≥ 10 days of therapy), adverse reaction, or contraindication to clonidine.

 

temazepam 22.5 mg for members < six years of age

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • treatment plan including name of current hypnotic agent and corresponding diagnosis; and
    • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult was provided.

 

 

†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: 03/2013

Last Revised Date: 03/2024


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Last updated 05/16/24

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