FDA-approved, for example:

• Influenza Type A and B (oseltamivir ≥ two weeks of age; Relenza ≥ seven years of age; Xofluza ≥ 12 years of age)
• Prophylaxis of Influenza Type A and B (oseltamivir ≥ one year of age; Relenza ≥ five years of age; Xofluza ≥ 12 years of age)

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.

Prophylaxis

oseltamivir and Relenza

• Documentation of all of the following is required for prophylaxis requests above the quantity limit:
  • if the request is for Relenza, member is five years of age or older; and
  • one of the following:
    • member is a resident in an institutional setting; or
    • both of the following:
      • one of the following:
        • member with likely exposure to others with confirmed, probable, or suspected influenza infection and are at risk of developing influenza-related complications with at least one risk factor, including:
          • members ≥ 65 years of age; or
          • members ≤ five years of age; or
          • members < 19 years of age who are receiving long-term aspirin therapy; or
          • residents of nursing homes or chronic care facilities; or
          • pregnant members and members up to two weeks postpartum; or
          • members with chronic medical conditions including: 
            • chronic pulmonary disease (e.g., asthma, chronic obstructive pulmonary disease, cystic fibrosis); or
            • cardiovascular disease (except isolated hypertension); or
            • renal dysfunction; or
            • hepatic dysfunction; or
            • chronic metabolic or endocrine disease (e.g., diabetes mellitus, mitochondrial disease); or
            • hemoglobinopathies (e.g., sickle cell disease); or
            • immunosuppression, including HIV infection, organ or hematopoietic cell transplantation, malignancy (if prescriber notes immunosuppression is a concern), and inflammatory disorders treated with immunosuppressants; or
            • neurologic conditions that compromise handling of respiratory secretions (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, neuromuscular disorders); or
          • members from certain racial and ethnic minority groups are at increased risk for hospitalization with flu, including non-Hispanic Black members, Hispanic or Latino members, and American Indian or Alaska Native members; or
          • members who are morbidly obese (body mass index ≥ 40); or
        • members who work in institutions caring for individuals at high risk of serious complications of influenza infection during an institutional outbreak; and
      • one of the following:
        • requested dose and duration is consistent with current CDC recommendations; or
        • medical necessity for going above standard dosing or duration recommendations.

SmartPA: Claims for oseltamivir above quantity limits and Relenza above quantity limits (in members ≥ five years) will usually process at the pharmacy without a PA if MassHealth pharmacy claims data indicate the member is currently in an institutional setting.^†

Treatment

oseltamivir and Relenza

• Documentation of all of the following is required for treatment requests above the quantity limit:
  • if the request is for Relenza, member is seven years of age or older; and
  • one of the following:
    • member is a resident in an institutional setting; or
    • all of the following:
      • member with confirmed, probable, or suspected influenza; and
      • member is at high risk for developing serious influenza-related complications with at least one risk factor (see above); and 
      • one of the following:
        • requested dose and duration is consistent with current CDC recommendations; or
        • medical necessity for going above standard dosing or duration recommendations.

SmartPA: Claims for oseltamivir above quantity limits and Relenza above quantity limits (in members ≥ five years) will usually process at the pharmacy without a PA if MassHealth pharmacy claims data indicate the member is currently in an institutional setting.^†

Xofluza

• Documentation of all of the following is required for prophylaxis or treatment requests:
  • member is 12 years of age or older; and
  • one of the following: 
    • member with confirmed, probable, or suspected influenza; or
    • member with exposure to an individual with confirmed influenza infection; and
  • medical necessity for the use of single-dose preparation instead of treatment course with oseltamivir capsules; and
  • appropriate dosing; and
  • one of the following:
    • for the 20 mg tablet, requested quantity is ≤ two tablets per treatment; or
    • for the 40 mg and 80 mg tablets, requested quantity is ≤ one tablet per treatment.

† 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.