FDA-approved, for example:

• Diaper dermatitis complicated by candidiasis – miconazole/zinc oxide ointment
• Onychomycosis – Jublia and tavaborole
• Seborrheic dermatitis – ciclopirox and ketoconazole
• Superficial tinea or candida (fungal) infections
• Vulvovaginal candidiasis – vaginal formulations only

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 diagnosis (see below).

ciclopirox gel and shampoo, Ertaczo, Exelderm, ketoconazole foam, luliconazole, naftifine, oxiconazole

• Documentation of all of the following is required.
  • appropriate diagnosis; and
  • one of the following:
    • inadequate response (within the last 90 days) or adverse reaction to two different clinically appropriate generic topical antifungals available without PA; or
    • contraindication to all clinically appropriate agents available without PA.

Please note: Unless a contraindication to all medications available without PA exists, two agents must be tried.

SmartPA: Claims for ciclopirox gel and shampoo, Ertaczo, Exelderm, ketoconazole foam, luliconazole, naftifine, and oxiconazole will usually process at the pharmacy without a prior authorization request if the member has a history of paid MassHealth pharmacy claims for two different generic topical antifungals available without PA within the most recent 90 days.^†

clotrimazole/betamethasone lotion

• Documentation of all of the following is required.
  • appropriate diagnosis; and
  • inadequate response (within the last 90 days), adverse reaction or contraindication to clotrimazole/betamethasone cream.

SmartPA: Claims for clotrimazole/betamethasone lotion will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for clotrimazole/betamethasone cream within the most recent 90 days.^†

ciclopirox powder, fluconazole powder, griseofulvin powder, itraconazole powder, miconazole nitrate powder, terbinafine powder

• Documentation of the following is required.  
  • appropriate diagnosis; and
  • clinical rationale why other commercially available alternatives cannot be used.

Jublia, tavaborole

• Documentation of the following is required.  
  • appropriate diagnosis; and
  • one of the following:
    • inadequate response or adverse reaction to terbinafine oral tablets; or
    • medical necessity for topical formulation and inadequate response to 24 consecutive weeks of therapy or adverse reaction to ciclopirox nail solution; or
    • contraindication to terbinafine oral tablets and ciclopirox nail solution; and
  • if the request is for tavaborole, medical records documenting inadequate response to 48 weeks of therapy, adverse reaction, or contraindication to Jublia.  

miconazole/zinc oxide ointment

• Documentation of all of the following is required.
  • appropriate diagnosis; and
  • inadequate response, adverse drug reaction, or contraindication to two of the following less costly topical antifungal agents: clotrimazole, ketoconazole, miconazole, nystatin.

^†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.