FDA-approved, for example:

• Atopic dermatitis (eczema)
• Plaque psoriasis 
• Vitiligo

Non-FDA-approved, for example:

• Alopecia areata

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
  • 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
  • member is ≥ 12 years of age; and
  • inadequate response or adverse rection to one or contraindication to both of the following: topical corticosteroids, topical calcineurin inhibitors; and
  • inadequate response, adverse reaction or contraindication to Eucrisa; and
  • one of the folowing:
    • 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 both of the following: topical corticosteroids and 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 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 topical corticosteroid, or contraindication to all topical corticosteroids; and
  • inadequate response or adverse reaction to one intralesional corticosteroid, or contraindication to all intralesional corticosteroids; and
  • inadequate response or adverse reaction to one of the following, or contraindication to all of the following: Olumiant (baricitinib), Xeljanz (tofacitinib), Xeljanz XR (tofacitinib extended-release).

Vtama

• Documentation of all of the following is required:
  • diagnosis of plaque psoriasis; and
  • member is ≥ 18 years of age; and
  • 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

• Documentation of all of the following is required:
  • diagnosis of plaque psoriasis; and
  • member is ≥ 12 years of age; and
  • inadequate response or adverse reaction to two of the following, 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.

^†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.