FDA-approved, for example:

• Atopic dermatitis (eczema)
• Plaque psoriasis 
• Seborrheic dermatitis
• Vitiligo

Non-FDA-approved, for example:

• Alopecia areata
• Seborrheic dermatitis

Note: The above lists may not include all FDA-approved and non-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.

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:
    • both of the following:
      • member has atopic dermatitis on the face or areas at high risk for skin atrophy (e.g., intertriginous areas, genitals); and
      • inadequate response, adverse reaction, or contraindication to a topical calcineurin inhibitor; or
    • inadequate response or adverse reaction to one or contraindication to both of the following: topical corticosteroids, topical calcineurin inhibitors; and
  • one of the following:
    • requested quantity is ≤ 60 grams/30 days; or
    • medical necessity for exceeding the quantity limit.

SmartPA: Claims for ≤ 60 grams/30 days 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 for a diagnosis of atopic dermatitis:
  • appropriate diagnosis; and
  • one of the following: 
    • both of the following:
      • member is ≥ two years and < 12 years of age; and
      • prescriber is a dermatologist or consult notes from a dermatologist are provided; or
    • member is ≥ 12 years of age; and
  • inadequate response, adverse reaction, or contraindication to a topical calcineurin inhibitor; and
  • one of the following:
    • requested quantity is  ≤ 60 grams/30 days; or
    • medical necessity for exceeding the quantity limit.

• Documentation of all of the following is required for a diagnosis of vitiligo:
  • appropriate diagnosis; and
  • prescriber is a dermatologist or consult notes from a dermatologist are provided; and
  • member is ≥ 12 years of age; and
  • total body surface area (BSA) to be treated is ≤ 10%; and
  • inadequate response, adverse reaction, or contraindication to a topical calcineurin inhibitor; and
  • one of the following:
    • requested quantity is  ≤ 60 grams/30 days; or
    • medical necessity for exceeding the quantity limit.

• Documentation of all of the following is required for a diagnosis of alopecia areata:
  • appropriate diagnosis; and
  • prescriber is a dermatologist or consult notes from a dermatologist are provided; and
  • member is ≥ 12 years of age; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: Olumiant, Xeljanz, Xeljanz XR; and
  • one of the following:
    • requested quantity is  ≤ 60 grams/30 days; or
    • medical necessity for exceeding the quantity limit; and
  • one of the following:
    • both of the following:
      • inadequate response or adverse reaction to one topical corticosteroid, or contraindication to all topical corticosteroids; and
      • inadequate response or adverse reaction to one intralesional corticosteroid, or contraindication to all intralesional corticosteroids; or
    • member has a large area of hair loss (e.g. ≥ 25 percent scalp hair loss).

pimecrolimus

• Documentation of all of the following is required:
  • diagnosis of atopic dermatitis; and
  • member is ≥ two years of age; and
  • one of the following:
    • member has atopic dermatitis on the face or areas at high risk for skin atrophy (e.g., intertriginous areas, genitals); or
    • inadequate response, adverse reaction, or contraindication to a topical corticosteroid; and
  • one of the following:
    • for members <16 years of age, inadequate response, adverse reaction, or contraindication to topical tacrolimus 0.03%; or
    • for members ≥16 years of age, inadequate response, adverse reaction, or contraindication to topical tacrolimus; and
  • one of the following:
    • requested quantity is ≤ 100 grams/30 days; or
    • medical necessity for exceeding the quantity limit.

SmartPA: Claims for ≤ 100 grams/30 days of pimecrolimus will usually process at the pharmacy without a PA request if the member is ≥ two years of age, has a history of a paid MassHealth pharmacy claim for one topical corticosteroid, and a history of paid claim for topical tacrolimus for members ≥ 16 years of age or tacrolimus 0.03% for members < 16 years of age in all claims history .^†

Vtama

• Documentation of all of the following is required:
  • diagnosis of plaque psoriasis; and
  • member is ≥ 18 years of age; and
  • one of the following:
    • both of the following:
      • member has plaque psoriasis on the face or areas at high risk for skin atrophy (e.g., intertriginous areas, genitals); and
      • inadequate response, adverse reaction, or contraindication to both of the following: topical calcineurin inhibitors, vitamin D analogs; or
    • inadequate response or adverse reaction to two or contraindication to all of the following: topical corticosteroids, topical calcineurin inhibitors, vitamin D analogs; and
  • one of the following:
    • requested quantity is ≤ 60 grams/30 days; or
    • medical necessity for exceeding the quantity limit.

Zoryve 0.15% cream

• Documentation of all of the following is required:
  • diagnosis of atopic dermatitis; and
  • member is ≥ six years of age; and
  • inadequate response, adverse reaction, or contraindication to a topical calcineurin inhibitor; and
  • one of the following:
    • requested quantity is ≤ 60 grams/30 days; or
    • medical necessity for exceeding the quantity limit.

Zoryve 0.3% cream

• Documentation of all of the following is required:
  • diagnosis of plaque psoriasis; and
  • member is ≥ six years of age; and
  • one of the following:
    • both of the following:
      • member has plaque psoriasis on the face or areas at high risk for skin atrophy (e.g., intertriginous areas, genitals); and
      • inadequate response or adverse reaction to one or contraindication to both of the following: topical calcineurin inhibitors, vitamin D analogs; or
    • inadequate response or adverse reaction to one or contraindication to all of the following: topical calcineurin inhibitors, topical corticosteroids, vitamin D analogs; and
  • one of the following:
    • requested quantity is ≤ 60 grams/30 days; or
    • medical necessity for exceeding the quantity limit.

Zoryve foam

• Documentation of all of the following is required for the diagnosis of seborrheic dermatitis:
  • appropriate diagnosis; and
  • member is ≥ nine years of age; and
  • one of the following:
    • both of the following:
      • member has seborrheic dermatitis on the face or areas at high risk for skin atrophy (e.g., intertriginous areas, genitals); and
      • inadequate response or adverse reaction to one or contraindication to both of the following: topical antifungals, topical calcineurin inhibitors; or
    • inadequate response or adverse reaction to one or contraindication to all of the following: topical antifungals, topical corticosteroids, topical calcineurin inhibitors; and
  • one of the following:
    • requested quantity is ≤ 60 grams/30 days; or
    • medical necessity for exceeding the quantity limit.

• Documentation of all of the following is required for the diagnosis of plaque psoriasis:
  • appropriate diagnosis; and
  • member is ≥ 12 years of age; and
  • one of the following:
    • both of the following:
      • member has plaque psoriasis on the face or areas at high risk for skin atrophy (e.g., intertriginous areas, genitals); and
      • inadequate response or adverse reaction to one or contraindication to both of the following: topical calcineurin inhibitors, vitamin D analogs; or
    • inadequate response or adverse reaction to one or contraindication to all of the following: topical calcineurin inhibitors, topical corticosteroids, vitamin D analogs; and
  • one of the following: 
    • requested quantity is ≤ 60 grams/30 days; or
    • medical necessity for exceeding the quantity limit.

^†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.