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.

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).