FDA-approved, for example:

• Atopic dermatitis (eczema)

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.
• 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 the member’s condition and  requested medication (see below).

Eucrisa

• Documentation of all of the following is required:
  • diagnosis of atopic dermatitis; and
  • member is ≥ three months of age; and
  • one of the following:
    • inadequate response or adverse reaction to one topical corticosteroid or topical calcineurin inhibitor; or
    • contraindication to both topical corticosteroids and topical calcineurin inhibitors; and
  • one of the following:
    • request is for 60 grams/month; or
    • medical necessity for exceeding the quantity limits.

SmartPA: Claims for ≤ 60 grams/month of Eucrisa will usually process at the pharmacy without a PA request if the member is ≥ three months of age, has a history of MassHealth medical claims for atopic dermatitis, and has a history of a paid MassHealth pharmacy claim for one topical corticosteroid or one topical calcineurin inhibitor.^†

Opzelura

• Documentation of all of the following is required;
  • diagnosis of atopic dermatitis; and
  • member is ≥ 12 years of age; and
  • one of the following;
    • inadequate response or adverse rection to one topical corticosteroid or topical calcineurin inhibitor; or
    • contraindication to both topical corticosteroids and topical calcineurin inhibitors; and
  • inadequate response, adverse reaction or contraindication to Eucrisa; and
  • one of the folowing:
    • request is for 60 grams/month; or
    • medical necessity for exceeding the quantity limits.

SmartPA: Claims for ≤ 60 grams/month of Opzelura will usually process at the pharmacy without a PA request if the member is ≥ 12 years of age, has a history of MassHealth medical claims for atopic dermatitis, has a history of a paid MassHealth pharmacy claim for one topical corticosteroid or one topical calcineurin inhibitor and has a history of a paid MassHealth pharmacy claim for Eucrisa.^†

^†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.

Please note: The MassHealth agency does not pay for any drug when used for cosmetic purposes as described in 130 CMR 406.413(B) “Limitations on Coverage of Drugs – Drug Exclusions” (see link below).

https://www.mass.gov/regulations/130-CMR-406000-pharmacy-services