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Table 71: Pediatric Behavioral Health


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Drug Category: Behavioral Health

Medication Class/Individual Agents: various

I. Prior-Authorization Requirements

 Pediatric Behavioral Health – Alpha Agonists

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

clonidine patch Catapres-TTS PA   BP
clonidine powder PA  
clonidine tablet PA   - < 3 years
guanfacine PA   - < 3 years

Please note: For a comprehensive list of all behavioral health medications included in the Pediatric Behavioral Health Medication Initiative, please see Appendix I below.  The member will need to meet all criteria for the requested agent as specified in the respective medication class guideline, if applicable.

 

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.

  • The American Academy of Child and Adolescent Psychiatry Practice Parameter on the use of Psychotropic Medications in Children and Adolescents encourages a complete medical and psychiatric evaluation before initiation of pharmacotherapy, a psychosocial and psychopharmacological treatment and monitoring strategy, and patient and family education about the treatment plan.1
  • A treatment and monitoring plan is essential to properly assess therapy response and adverse effects upon initiation, dose optimization, and discontinuation.  Appropriate follow-up allows for opportunities to educate the patient and family/caregiver and to address treatment plan concerns.1
  • Evidence-based and age-appropriate psychosocial treatments should be tried prior to psychopharmacologic treatments in pediatric patients as clinically appropriate.2 Pharmacological treatments should be reserved for patients who have not responded to psychological treatment and if benefits outweigh the risks associated with treatment.3
  • Psychotherapy in combination with pharmacotherapy may lead to more favorable outcomes compared to either treatment alone.4,5 Patient and family/caregiver education about the importance of both interventions is essential.6
  • With initial treatment non-response, dose optimization or switching to an alternative agent should be considered prior to polypharmacy when clinically appropriate.7 Prescribers should have clear rationale for use of medication combinations to treat a condition, multiple comorbidities, and/or adverse effects resulting from therapy.1 At this time there is limited evidence supporting the use of medication polypharmacy from the same medication class, especially in the pediatric and adolescent population.1
  • Refractory patients and those considered as being a risk to self or others should be referred to a specialist provider.7

References:

1 American Academy of Child and Adolescent Psychiatry. Practice parameter on the use of psychotropic medications in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2006;48(9):961-73.

2 Gleason MM, Egger HL, Emslie GJ, Greenhill LL, Kowatch RA, Lieberman AF, et al. Psychopharmacological treatment for the very young: contexts and guidelines. J Am Acad Child Adolesc Psychiatry. 2007;46(12):1532-72.

3 Anderson IM, Ferrier IN, Baldwin RC, Cowen PJ, Howard L, Lewis G, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for the Psychopharmacology guidelines. J Psychopharmacology. 2008;22(4):343-96.

4 Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med 2008;359(26):2753-66.

5 March J, Silva S, Petrycki S, CurryJ, Wells K, Fairbank J, et al. Fluoxetine, cognitive-behavioral therapy and their combination for adolescents with depression: treatment for adolescents with depression (TADS) randomized controlled-trial. JAMA.2004;292(7):807-20.

6 Stroeh O and Trivedi H. Appropriate and judicious use of psychotropic medications in youth. Child Adolesc Psychiatric Clin N Am. 2012;21:703-11.

7 Balwin DS, Anderson IM, Nutt DJ, Allqulander C, Bandelow B, den Boer JA,  et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacology. 2014;28(5):403-39.

 

 Pediatric Behavioral Health – Antianxiety Agents - Benzodiazepines

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

alprazolam Xanax PA   - < 6 years #
alprazolam extended-release Xanax XR PA   - < 6 years and PA > 2 units/day #
alprazolam orally disintegrating tablet PA  
alprazolam powder 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 powder PA  
clonazepam tablet Klonopin PA   - < 6 years #
clorazepate Tranxene PA  
diazepam powder PA  
diazepam solution, tablet PA   - < 6 years
lorazepam extended-release Loreev XR PA  
lorazepam powder PA  
lorazepam solution, tablet Ativan PA   - < 6 years #
midazolam powder PA  
midazolam syrup PA   - < 6 years
oxazepam PA  

 Pediatric Behavioral Health – Antianxiety Agents - Not Otherwise Classified

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

amitriptyline / chlordiazepoxide PA  
buspirone PA   - < 6 years
buspirone powder PA  
meprobamate PA  

 Pediatric Behavioral Health – Antidepressants - Monoamine Oxidase Inhibitors (MAOI)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

isocarboxazid Marplan PA  
phenelzine Nardil PA   - < 6 years #
selegiline transdermal patch Emsam PA  
tranylcypromine PA   - < 6 years

 Pediatric Behavioral Health – Antidepressants - NMDA Receptor Antagonist

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

esketamine Spravato PA  

 Pediatric Behavioral Health – Antidepressants - Noradrenergic and Specific Serotonergic Antidepressants (NaSSA)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

mirtazapine Remeron PA   - < 6 years #
mirtazapine orally disintegrating tablet Remeron Sol Tab PA  

 Pediatric Behavioral Health – Antidepressants - Norepinephrine/Dopamine Reuptake Inhibitors (NDRI)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

bupropion hydrobromide extended-release Aplenzin PA   - < 6 years and PA > 1 unit/day
bupropion hydrochloride PA   - < 6 years
bupropion hydrochloride extended-release 150 mg, 300 mg tablets Wellbutrin XL PA   - < 6 years and PA > 1 unit/day #
bupropion hydrochloride extended-release 450 mg tablet Forfivo XL PA   BP
bupropion hydrochloride sustained-release-Wellbutrin SR Wellbutrin SR PA   - < 6 years #
bupropion hydrochloride sustained-release-Zyban Zyban PA   - < 6 years #

 Pediatric Behavioral Health – Antidepressants - Selective Serotonin Reuptake Inhibitors (SSRI)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

citalopram capsule PA  
citalopram solution, tablet Celexa PA   - < 6 years #
escitalopram Lexapro PA   - < 6 years #
fluoxetine 10 mg, 20 mg tablet for premenstrual dysphoric disorder PA   - < 6 years
fluoxetine 10 mg, 20 mg, 40 mg capsule, solution Prozac PA   - < 6 years #
fluoxetine 60 mg tablet PA  
fluoxetine 90 mg delayed-release capsule PA  
fluvoxamine extended-release PA  
fluvoxamine immediate-release PA   - < 6 years
paroxetine controlled-release Paxil CR PA  
paroxetine hydrochloride Paxil PA   - < 6 years #
paroxetine mesylate Pexeva PA  
sertraline capsule PA  
sertraline oral concentrate, tablet Zoloft PA   - < 6 years #

 Pediatric Behavioral Health – Antidepressants - Serotonin Modulators

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

nefazodone PA   - < 6 years
trazodone 300 mg tablet PA  
trazodone 50 mg, 100 mg, 150 mg PA   - < 6 years
vilazodone Viibryd PA   BP
vortioxetine Trintellix PA  

 Pediatric Behavioral Health – Antidepressants - Serotonin/Norepinephrine Reuptake Inhibitors (SNRI)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

desvenlafaxine extended-release PA  
desvenlafaxine succinate extended-release Pristiq PA   - < 6 years and PA > 1 unit/day BP
duloxetine 20 mg, 30 mg, 60 mg capsule Cymbalta PA   - < 6 years #
duloxetine 40 mg capsule PA  
duloxetine sprinkle capsule Drizalma PA  
levomilnacipran Fetzima PA   - < 6 years and PA > 1 unit/day
venlafaxine PA   - < 6 years
venlafaxine extended-release capsule Effexor XR PA   - < 6 years #
venlafaxine extended-release tablet PA  

 Pediatric Behavioral Health – Antidepressants - Tricyclic Antidepressants (TCA)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

amitriptyline powder PA  
amitriptyline tablet PA   - < 6 years
amoxapine PA   - < 6 years
clomipramine Anafranil PA  
desipramine Norpramin PA  
doxepin capsule, oral concentrate PA   - < 6 years
imipramine hydrochloride PA   - < 6 years
imipramine pamoate PA  
maprotiline PA  
nortriptyline Pamelor PA   - < 6 years #
protriptyline PA  
trimipramine PA  

 Pediatric Behavioral Health – Cerebral Stimulants and Miscellaneous Agents - Long-Acting Amphetamine Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

amphetamine extended-release 1.25 mg/mL oral suspension Adzenys ER PA  
amphetamine extended-release 2.5 mg/mL oral suspension Dyanavel XR PA  
amphetamine extended-release orally disintegrating tablet Adzenys XR-ODT PA  
amphetamine salts extended-release-Adderall XR Adderall XR PA   - < 3 years and PA > 2 units/day BP
amphetamine salts extended-release-Mydayis Mydayis PA  
lisdexamfetamine capsule Vyvanse PA   - < 3 years and PA > 2 units/day
lisdexamfetamine chewable tablet Vyvanse PA  

 Pediatric Behavioral Health – Cerebral Stimulants and Miscellaneous Agents - Long-Acting Methylphenidate Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

dexmethylphenidate extended-release Focalin XR PD PA   - < 3 years and PA > 2 units/day BP
methylphenidate extended-release 72 mg tablet PA  
methylphenidate extended-release chewable tablet Quillichew ER PA  
methylphenidate extended-release oral suspension Quillivant XR PA  
methylphenidate extended-release orally disintegrating tablet Cotempla XR-ODT PA  
methylphenidate extended-release, CD PA  
methylphenidate extended-release-Adhansia XR Adhansia XR PA  
methylphenidate extended-release-Aptensio XR Aptensio XR PA  
methylphenidate extended-release-Concerta Concerta PA   - < 3 years and PA > 2 units/day BP
methylphenidate extended-release-Jornay PM Jornay PM PA  
methylphenidate transdermal Daytrana PA   - < 3 years and PA > 1 unit/day
methylphenidate-Ritalin LA Ritalin LA PA  
serdexmethylphenidate / dexmethylphenidate Azstarys PA  

 Pediatric Behavioral Health – Cerebral Stimulants and Miscellaneous Agents - Not Otherwise Classified

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

atomoxetine Strattera PA   - < 6 years BP
clonidine extended-release tablet PA  
guanfacine extended-release Intuniv PA   - < 3 years #
viloxazine Qelbree PA  

 Pediatric Behavioral Health – Cerebral Stimulants and Miscellaneous Agents - Short- and Intermediate-Acting Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

amphetamine salts Adderall PA   - < 3 years and PA > 3 units/day #
amphetamine sulfate PA  
amphetamine sulfate orally disintegrating tablet Evekeo ODT PA  
dexmethylphenidate Focalin PA   - < 3 years and PA > 3 units/day #
dextroamphetamine 2.5 mg, 7.5 mg, 15 mg, 20 mg, 30 mg tablet PA  
dextroamphetamine 5 mg, 10 mg tablet PA   - < 3 years and PA > 3 units/day
dextroamphetamine 5 mg, 10 mg, 15 mg capsule Dexedrine Spansule PA   - < 3 years and PA > 3 units/day #
dextroamphetamine solution PA   - < 3 years and PA > 40 mL/day
methamphetamine Desoxyn PA  
methylphenidate chewable tablet PA   - < 3 years and PA > 3 units/day
methylphenidate oral solution Methylin oral solution PA   - < 3 years and PA > 30 mL/day #
methylphenidate powder PA  
methylphenidate sustained-release tablet PA   - < 3 years and PA > 3 units/day
methylphenidate-Ritalin Ritalin PA   - < 3 years and PA > 3 units/day #

 Pediatric Behavioral Health – First-Generation (Typical) Antipsychotics

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

amitriptyline / perphenazine PA  
chlorpromazine PA   - < 6 years
fluphenazine PA   - < 6 years
haloperidol Haldol PA   - < 6 years #
loxapine capsule Loxitane PA   - < 6 years #
molindone PA   - < 6 years
perphenazine PA   - < 6 years
pimozide Orap PA   - < 6 years #
thioridazine PA   - < 6 years
thiothixene Navane PA   - < 6 years #
trifluoperazine PA   - < 6 years

 Pediatric Behavioral Health – Hypnotics

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

doxepin tablet-Silenor Silenor PA  
estazolam PA   - < 6 years and PA > 1 unit/day
eszopiclone Lunesta PA   - < 6 years and PA > 1 unit/day #
flurazepam PA   - < 6 years and PA > 1 unit/day
lemborexant Dayvigo PA  
suvorexant Belsomra PA  
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 #
zaleplon PA   - < 6 years and PA > 1 unit/day
zolpidem 1.75 mg, 3.5 mg sublingual tablet Intermezzo PA  
zolpidem 10 mg tablet Ambien PA   - < 6 years and PA > 1 unit/day #
zolpidem 5 mg tablet Ambien PA   - < 6 years and PA > 1.5 units/day #
zolpidem 5 mg, 10 mg sublingual tablet Edluar PA  
zolpidem extended-release tablet Ambien CR PA   - < 6 years and PA > 1 unit/day #

 Pediatric Behavioral Health – Mood Stabilizers

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

carbamazepine extended-release Carbatrol PA   - < 6 years #
carbamazepine extended-release Equetro PA   - < 6 years
carbamazepine extended-release Tegretol XR PA   - < 6 years #
carbamazepine-Tegretol Tegretol PA   - < 6 years #
divalproex extended-release Depakote ER PA   - < 6 years #
divalproex immediate-release Depakote PA   - < 6 years #
divalproex sprinkle capsule Depakote PA   - < 6 years BP
eslicarbazepine Aptiom PA  
gabapentin capsule, solution, tablet Neurontin PA   - < 6 years and PA > 3600 mg/day #
gabapentin powder PA  
lamotrigine dispersible tablet Lamictal PA   - < 6 years #
lamotrigine extended-release tablet Lamictal XR PA  
lamotrigine extended-release tablet starter kit Lamictal XR PA  
lamotrigine orally disintegrating tablet Lamictal ODT PA  
lamotrigine orally disintegrating tablet starter kit Lamictal ODT PA  
lamotrigine powder PA  
lamotrigine tablet Lamictal PA   - < 6 years #
lamotrigine tablet starter kit Lamictal PA  
lithium Lithobid PA   - < 6 years #
oxcarbazepine Trileptal PA   - < 6 years #
oxcarbazepine extended-release Oxtellar XR PA  
pregabalin Lyrica PA  
pregabalin extended-release Lyrica CR PA   BP
topiramate extended-release capsule-Qudexy XR Qudexy XR PA   - < 6 years #
topiramate extended-release capsule-Trokendi XR Trokendi XR PA   BP
topiramate powder PA  
topiramate solution Eprontia PA  
topiramate sprinkle capsule Topamax PA   - < 6 years #
topiramate tablet Topamax PA   - < 6 years #
valproic acid Depakene PA   - < 6 years #

 Pediatric Behavioral Health – Not Otherwise Classified

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

armodafinil Nuvigil PA   - < 6 years and PA > 1 unit/day #
donepezil 10 mg tablet Aricept PA   - < 6 years and PA > 2 units/day #
donepezil 5 mg, 23 mg tablet Aricept PA   - < 6 years and PA > 1 unit/day #
donepezil orally disintegrating tablet PA   - < 6 years and PA > 1 unit/day
memantine / donepezil extended-release Namzaric PA   - < 6 years and PA > 1 unit/day
memantine extended-release Namenda XR PA   - < 6 years and PA > 1 unit/day #
memantine solution PA  
memantine tablet Namenda PA   - < 6 years and PA > 2 units/day #
memantine titration pack Namenda PA   - < 6 years and PA > 49 units/28 days
modafinil 100 mg Provigil PA   - < 6 years and PA > 1.5 units/day #
modafinil 200 mg Provigil PA   - < 6 years and PA > 2 units/day #
naltrexone powder PA  
naltrexone tablet PA   - < 6 years

 Pediatric Behavioral Health – Second-Generation (Atypical) Antipsychotic and Opioid Antagonist

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

olanzapine / samidorphan Lybalvi PA  

 Pediatric Behavioral Health – Second-Generation (Atypical) Antipsychotic-Selective Serotonin Reuptake Inhibitor

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

olanzapine / fluoxetine Symbyax PA  

 Pediatric Behavioral Health – Second-Generation (Atypical) Antipsychotics

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

aripiprazole extended-release injection Abilify Maintena PA  
aripiprazole lauroxil 1,064 mg Aristada PD PA   - < 6 years and PA > 1 injection/2 months
aripiprazole lauroxil 441 mg, 662 mg, 882 mg Aristada PD PA   - < 6 years and PA > 1 injection/month
aripiprazole lauroxil 675 mg Aristada Initio PD PA   - < 6 years and PA > 1 injection/month
aripiprazole orally disintegrating tablet PA  
aripiprazole solution PA   - < 6 years or ≥ 18 years and PA > 25 mL/day
aripiprazole tablet Abilify PA   - < 6 years and PA > 2 units/day #
aripiprazole tablet with sensor Abilify Mycite PA  
asenapine sublingual tablet Saphris PA  
asenapine transdermal Secuado PA  
brexpiprazole Rexulti PA  
cariprazine Vraylar PA  
clozapine orally disintegrating tablet PA  
clozapine suspension Versacloz PA  
clozapine tablet Clozaril PA   - < 6 years #
iloperidone Fanapt PA  
lumateperone Caplyta PA  
lurasidone Latuda PA  
olanzapine 15 mg orally disintegrating tablet Zyprexa Zydis PA   - < 6 years and PA > 2 units/day #
olanzapine 210 mg, 300 mg extended-release injection Zyprexa Relprevv PA   - < 6 years and PA > 2 injections/month
olanzapine 405 mg extended-release injection Zyprexa Relprevv PA   - < 6 years and PA > 1 injection/month
olanzapine 5 mg, 10 mg, 20 mg orally disintegrating tablet Zyprexa Zydis PA   - < 6 years and PA > 1 unit/day #
olanzapine tablet Zyprexa PA   - < 6 years and PA > 2 units/day #
paliperidone extended-release 1-month injection Invega Sustenna PD PA   - < 6 years, PA > 2 injections/month within the first 30 days of therapy and PA > 1 injection/month after 30 days of therapy
paliperidone extended-release 3-month injection Invega Trinza PD PA   - < 6 years and PA > 1 injection/3 months
paliperidone extended-release 6-month injection Invega Hafyera PD PA   - < 6 years and PA > 1 injection/6 months
paliperidone tablet Invega PA   BP
quetiapine Seroquel PA   - < 6 years and PA > 3 units/day #
quetiapine extended-release Seroquel XR PA   - < 6 years and PA > 2 units/day #
risperidone 0.25 mg, 0.5 mg, 1 mg, 2 mg orally disintegrating tablet PA   - < 6 years and PA > 2 units/day
risperidone 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg tablets Risperdal PA   - < 6 years and PA > 2 units/day #
risperidone 3 mg, 4 mg orally disintegrating tablet PA  
risperidone 4 mg tablet Risperdal PA   - < 6 years and PA > 4 units/day #
risperidone extended-release intramuscular injection Risperdal Consta PA   - < 6 years and PA > 2 injections/month
risperidone extended-release subcutaneous injection Perseris PA  
risperidone solution Risperdal PA   - < 6 years and PA > 16 mL/day #
ziprasidone capsule Geodon PA   - < 6 years and PA > 2 units/day #
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization 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.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 
PD Preferred Drug. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Anxiety
  • Attention Deficit Hyperactivity Disorder (ADHD)
  • Bipolar disorder
  • Depression
  • Hyperactivity associated with autism spectrum disorder
  • Psychotic disorders
  • Schizophrenia
  • Tourette Disorder

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.
  • 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).

       

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

  

 **Please note: The member will need to meet all criteria for the requested agent as specified in the respective medication class table, if applicable.**

 

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 old

  • 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.

 

Antidepressant Polypharmacy (overlapping pharmacy claims for two or more antidepressants for at least 60 days within a 90-day period) for members < 18 years old

  • 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 psychiatric diagnosis; and
      • treatment plan including names of current antidepressants and corresponding diagnoses; and
      • prescriber is a psychiatrist or consult is provided; and
      • one of the following:
        • cross-titration/taper of antidepressant therapy; or
        • inadequate response (defined as four weeks of therapy) or adverse reaction to two monotherapy trials as clinically appropriate; or
        • antidepressant polypharmacy regimen of ≤ two antidepressants includes one of the following: bupropion, mirtazapine or trazodone; or
        • one antidepressant in the regimen is indicated for a comorbid condition in which antidepressants may be clinically appropriate.

SmartPA: Claims 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 for two antidepressants for at least 60 days of therapy out of the last 90 days and one or both agents are trazodone, mirtazapine, or bupropion.

 

Antipsychotic Polypharmacy (overlapping pharmacy claims for two or more antipsychotics [includes first-generation and/or second-generation antipsychotics, except short-acting injectable formulations] for at least 60 days within a 90-day period) for members < 18 years old

  • or 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:

      • treatment plan including name, dose, and frequency of all current behavioral health medications, associated target symptom(s), and behavioral health diagnoses; and
      • a comprehensive behavioral health plan (i.e. non-pharmacologic interventions) is in place; and
      • prescriber is a psychiatrist or consult is provided; and
      • stage of treatment is acute, maintenance, or discontinuation; and
      • one of the following:
        • for acute stage (initiation of antipsychotic treatment likely with subsequent dose adjustments to maximize response and minimize side effects), one of the following:
          • cross-titration/taper of antipsychotic therapy; or
          • inadequate response or adverse reaction to two monotherapy trials as clinically appropriate; or
        • for maintenance stage (response to antipsychotic treatment with goal of remission or recovery), all of the following:
          • regimen is effective, therapy benefits outweigh risks, and appropriate monitoring is in place; and
          • if member has been on the antipsychotic regimen for the past 12 months, clinical rationale for extended therapy including at least one of the following: previous efforts to reduce/simplify the antipsychotic regimen in the past 24 months resulted in symptom exacerbation; or family/caregiver does not support the antipsychotic regimen change at this time due to risk of exacerbation; or other significant barrier for antipsychotic therapy discontinuation; or
        • for discontinuation stage (clinically indicated that the antipsychotic regimen can likely be successfully tapered), cross-titration/taper of antipsychotic therapy.

 

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 old

  • 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.

 

Cerebral Stimulant Polypharmacy (overlapping pharmacy claims for two or more cerebral stimulants [immediate-release and extended-release formulations of the same chemical entity are counted as one] for at least 60 days within a 90-day period) for members < 18 years old

  • 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 cerebral stimulants and corresponding diagnoses; and
      • inadequate response (defined as > seven days of therapy), adverse reaction, or contraindication to monotherapy trial with a methylphenidate product; and
      • inadequate response (defined as > seven days of therapy), adverse reaction, or contraindication to monotherapy trial with an amphetamine product; and
      • clinical rationale for cerebral stimulant polypharmacy.

 

Mood Stabilizer Polypharmacy (overlapping pharmacy claims for three or more mood stabilizers [agents considered to be used only for seizure diagnoses are not included] for at least 60 days within a 90-day period) for members < 18 years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required for members with seizure diagnosis only:
    • appropriate diagnosis (seizure) without comorbid condition.

 

  • Documentation of the following is required for members with psychiatric diagnoses, with or without 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 psychiatric diagnoses; and
      • treatment plan including names of current mood stabilizers and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; 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.

 

  • Documentation of the following is required for members with a diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain), with or without 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 in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain); and
      • treatment plan including names of current mood stabilizers and corresponding diagnoses; and
      • other clinically appropriate therapies have been tried and failed; therefore, multiple mood stabilizers are needed.

 

  • Documentation of the following is required for members with a psychiatric diagnosis and comorbid diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain), with or without 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:
      • psychiatric diagnosis and diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain); and
      • treatment plan including names of current mood stabilizers and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; and
      • 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.

 

Antidepressant, armodafinil, buspirone, donepezil, memantine, modafinil, or naltrexone for members < six years old

  • 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.

 

 Antipsychotic for members < six years old

  • 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:
      • complete medication treatment plan including name, dose, and frequency of all current behavioral health medications, associated target symptom(s), and behavioral health diagnoses; and
      • a comprehensive behavioral health treatment plan (i.e., non-pharmacological interventions) is in place; and
      • prescriber is a specialist (e.g. child psychiatry, pediatric neurology, or developmental/behavioral pediatrics) or consult is provided; and
      • one of the following:
        • member is in acute stage of treatment (initiation of antipsychotic treatment likely with subsequent dose adjustments to maximize response and minimize side effects); or
        • all of the following:
          • member is in maintenance stage of treatment (response to antipsychotic treatment with goal of remission or recovery); and
          • regimen is effective, therapy benefits outweigh risks, and appropriate monitoring is in place; and
          • if member has been on the antipsychotic regimen for the past 12 months, clinical rationale for extended therapy including at least one of the following: previous efforts to reduce/simplify the antipsychotic regimen in the past 12 months resulted in symptom exacerbation; or family/caregiver does not support the antipsychotic regimen change at this time due to risk of exacerbation; or other significant barrier for antipsychotic therapy discontinuation; or
        • all of the following:
          • member is in discontinuation stage of treatment (clinically indicated that the antipsychotic regimen can likely be successfully tapered); and
          • cross-titration/taper of antipsychotic therapy.

 

Atomoxetine and viloxazine for members < six years old

  • 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
      • if member is < three years old, prescriber is a specialist (e.g. psychiatrist) or consult is provided.

 

Benzodiazepine (hypnotic benzodiazepine agents are not included) or Mood Stabilizer (agents considered to be used only for seizure diagnoses are not included) for members < six years old

  • 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).

 

Alpha2 Agonist for members < three years old

  • 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 cardiovascular diagnosis only; or
    • all of the following:
      • appropriate diagnosis; and
      • treatment plan including names of current alpha2 agonist(s) and corresponding diagnoses; and
      • clinical rationale for use of alpha2 agonist in member < three years old.

 

Cerebral Stimulant for members < three years old

  • 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 cerebral stimulant(s) and corresponding diagnoses; and
      • clinical rationale for use of cerebral stimulant in member < three years old.

 

Estazolam, eszopiclone, flurazepam, temazepam 7.5 mg, 15 mg, and 30 mg, triazolam, zaleplon, zolpidem tablet, and zolpidem extended-release tablet for members < six years old

  • 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 ≥ ten 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 ≥ ten days of therapy), adverse reaction, or contraindication to melatonin; and
    • inadequate response (defined by ≥ ten days of therapy), adverse reaction, or contraindication to clonidine.

 

Other hypnotic agents (Belsomra, Dayvigo, doxepin tablet, Edluar, temazepam 22.5 mg, and zolpidem 1.75 mg, 3.5 mg sublingual tablet) for members < six years old

  • 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.

 

The following behavioral health medications are included in the Pediatric Behavioral Health Medication Initiative:

Appendix I:


Pediatric Behavioral Health Medication Initiative Medication List1

Antidepressants

Mood Stabilizers

amitriptyline

maprotiline

carbamazepine

lithium

amoxapine

mirtazapine

divalproex

oxcarbazepine

bupropion

nefazodone

eslicarbazepine

pregabalin

citalopram

nortriptyline

gabapentin

topiramate

clomipramine

paroxetine

lamotrigine

valproic acid

desipramine

phenelzine

Antianxiety Agents

desvenlafaxine

protriptyline

alprazolam

diazepam3

doxepin

selegiline2

buspirone

lorazepam

duloxetine

sertraline

chlordiazepoxide

meprobamate

escitalopram

tranylcypromine

chlordiazepoxide/ amitriptyline

midazolam3

esketamine

trazodone

clonazepam

oxazepam

fluoxetine

trimipramine

clorazepate

 

fluvoxamine

venlafaxine

Hypnotics

imipramine

vilazodone

doxepin4

suvorexant

isocarboxazid

vortioxetine

estazolam

temazepam

levomilnacipran

 

eszopiclone

triazolam

Antipsychotics

flurazepam

zaleplon

aripiprazole

olanzapine

lemborexant

zolpidem

asenapine

olanzapine/fluoxetine

Alpha2 Agonists

brexipiprazole

olanzapine/samidorphan

clonidine

guanfacine

cariprazine

paliperidone

Stimulants

chlorpromazine

perphenazine

amphetamine

lisdexamfetamine

clozapine

perphenazine/amitriptyline

dextroamphetamine

methamphetamine

fluphenazine

pimozide

dexmethylphenidate

methylphenidate

haloperidol

quetiapine

dextroamphetamine/ amphetamine

serdexmethylphenidate/ dexmethylphenidate

iloperidone

risperidone

Miscellaneous

loxapine

thioridazine

armodafinil

modafinil

lumateperone

thiothixene

atomoxetine

naltrexone5

lurasidone

trifluoperazine

donepezil

viloxazine

molindone

ziprasidone

memantine

 

1Short-acting intramuscular injectable and intravenous formulations are excluded from the Pediatric Behavioral Health Medication Initiative requirements.

2Emsam (selegiline) is the only selegiline formulation included in the Pediatric Behavioral Health Medication Initiative.

3Nasal and rectal diazepam and nasal midazolam formulations are excluded from the Pediatric Behavioral Health Medication Initiative requirements.

4Doxepin tablet is classified as a hypnotic agent and the Pediatric Behavioral Health Medication Initiative requirements for antidepressants do not apply. Pediatric Behavioral Health Medication Initiative requirements for hypnotics apply.

5Vivitrol (naltrexone injection) is excluded from the Pediatric Behavioral Health Medication Initiative requirements.

†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: 11/2014

Last Revised Date: 02/2022


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Last updated 05/09/22

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