Table 71: Pediatric Behavioral Health
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: Behavioral Health
Medication Class/Individual Agents: various
I. Prior-Authorization Requirements
Pediatric Behavioral Health – Alpha Agonists |
Clinical Notes |
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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.
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. |
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Pediatric Behavioral Health – Antianxiety Agents - Benzodiazepines |
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Pediatric Behavioral Health – Antianxiety Agents - Not Otherwise Classified |
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Pediatric Behavioral Health – Antidepressants - Monoamine Oxidase Inhibitors (MAOI) |
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Pediatric Behavioral Health – Antidepressants - NMDA Receptor Antagonist |
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Pediatric Behavioral Health – Antidepressants - Noradrenergic and Specific Serotonergic Antidepressants (NaSSA) |
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Pediatric Behavioral Health – Antidepressants - Norepinephrine/Dopamine Reuptake Inhibitors (NDRI) |
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Pediatric Behavioral Health – Antidepressants - Selective Serotonin Reuptake Inhibitors (SSRI) |
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Pediatric Behavioral Health – Antidepressants - Serotonin Modulators |
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Pediatric Behavioral Health – Antidepressants - Serotonin/Norepinephrine Reuptake Inhibitors (SNRI) |
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Pediatric Behavioral Health – Antidepressants - Tricyclic Antidepressants (TCA) |
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Pediatric Behavioral Health – Antidepressants – Gamma-Aminobutyric (GABA)-A Receptor Positive Modulator |
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Pediatric Behavioral Health – Cerebral Stimulants and Miscellaneous Agents - Long-Acting Amphetamine Agents |
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Pediatric Behavioral Health – Cerebral Stimulants and Miscellaneous Agents - Long-Acting Methylphenidate Agents |
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Pediatric Behavioral Health – Cerebral Stimulants and Miscellaneous Agents - Not Otherwise Classified |
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Pediatric Behavioral Health – Cerebral Stimulants and Miscellaneous Agents - Short- and Intermediate-Acting Agents |
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Pediatric Behavioral Health – First-Generation (Typical) Antipsychotics |
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Pediatric Behavioral Health – Hypnotics |
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Pediatric Behavioral Health – Mood Stabilizers |
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Pediatric Behavioral Health – Not Otherwise Classified |
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Pediatric Behavioral Health – Second-Generation (Atypical) Antipsychotic and Opioid Antagonist |
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Pediatric Behavioral Health – Second-Generation (Atypical) Antipsychotic-Selective Serotonin Reuptake Inhibitor |
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Pediatric Behavioral Health – Second-Generation (Atypical) Antipsychotics |
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| # | 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. |
| 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. |
| 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:
- 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.
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.
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 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.
- one of the following:
- 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.
- one of the following:
Antidepressant Polypharmacy (overlapping pharmacy claims for two or more antidepressants 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
- 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.
- one of the following:
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 of age
- 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
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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.
- for acute stage (initiation of antipsychotic treatment likely with subsequent dose adjustments to maximize response and minimize side effects), one of the following:
- one of the following:
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.
- one of the following:
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 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 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.
- one of the following:
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 of age
- 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.
- one of the following:
- 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.
- one of the following:
- 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.
- one of the following:
Antidepressant, armodafinil, buspirone, donepezil, memantine, modafinil, or naltrexone 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.
- one of the following:
Antipsychotic 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:
- 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.
- one of the following:
Atomoxetine and viloxazine for members < six years of age
- 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 of age, prescriber is a specialist (e.g. psychiatrist) or consult is provided.
- one of the following:
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 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.
- one of the following:
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 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 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 of age.
- one of the following:
Cerebral Stimulant for members < three 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 cerebral stimulant(s) and corresponding diagnoses; and
- clinical rationale for use of cerebral stimulant in member < three years of age.
- one of the following:
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 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 ≥ 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, Quviviq, temazepam 22.5 mg, and zolpidem 1.75 mg, 3.5 mg sublingual tablet) 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.
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 |
levomilnacipran |
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 |
|
dextromethorphan/ bupropion |
selegiline2 |
buspirone |
lorazepam |
|
doxepin |
sertraline |
chlordiazepoxide |
meprobamate |
|
duloxetine |
tranylcypromine |
chlordiazepoxide/ amitriptyline |
midazolam3 |
|
escitalopram |
trazodone |
clonazepam |
oxazepam |
|
esketamine |
trimipramine |
clorazepate |
quazepam |
|
fluoxetine |
venlafaxine |
Hypnotics |
|
|
fluvoxamine |
vilazodone |
daridorexant |
suvorexant |
|
imipramine |
vortioxetine |
doxepin4 |
temazepam |
|
isocarboxazid |
zuranolone |
estazolam |
triazolam |
|
Antipsychotics |
eszopiclone |
zaleplon |
|
|
aripiprazole |
olanzapine |
flurazepam |
zolpidem |
| asenapine |
olanzapine/fluoxetine |
lemborexant |
|
|
brexipiprazole |
olanzapine/samidorphan |
Alpha2 Agonists |
|
|
cariprazine |
paliperidone |
clonidine |
guanfacine |
|
chlorpromazine |
perphenazine |
Stimulants |
|
|
clozapine |
perphenazine/amitriptyline |
amphetamine |
lisdexamfetamine |
|
fluphenazine |
pimozide |
dextroamphetamine |
methamphetamine |
|
haloperidol |
quetiapine |
dexmethylphenidate |
methylphenidate |
|
iloperidone |
risperidone |
dextroamphetamine/ amphetamine |
serdexmethylphenidate/ dexmethylphenidate |
|
loxapine |
thioridazine |
Miscellaneous |
|
|
lumateperone |
thiothixene |
armodafinil |
modafinil |
|
lurasidone |
trifluoperazine |
atomoxetine |
naltrexone5 |
|
molindone |
ziprasidone |
donepezil |
viloxazine |
|
|
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: 03/2024
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Last updated 04/01/24