FDA-approved, for example:

• Corticosteroid-responsive dermatoses with secondary infection
• Plaque psoriasis
• Psoriasis vulgaris
• Scalp-related conditions (i.e., dermatoses, psoriasis, seborrheic dermatitis)
• Topical inflammatory and pruritic dermatoses

 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.

amcinonide cream, clocortolone cream, desoximetasone 0.05% cream, gel, and ointment, desoximetasone 0.25% ointment and spray, diflorasone cream and ointment, flurandrenolide cream, lotion, and ointment, fluticasone lotion, halcinonide cream, halobetasol foam, hydrocortisone butyrate lotion, hydrocortisone solution, Locoid Lipocream, triamcinolone 0.05% ointment and spray, and brand-name topical corticosteroids (Apexicon-E, Bryhali, Halog solution, Ultravate lotion).

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • for Bryhali and desoximetasone spray, member is ≥ 18 years of age; and
  • for halobetasol foam and Ultravate lotion, member is ≥ 12 years of age; and
  • one of the following:
    • inadequate response or adverse reaction to all topical corticosteroids of the same potency range and formulation available without PA; or
    • medical necessity for the requested formulation.

betamethasone/calcipotriene ointment and topical suspension, and neomycin/fluocinolone cream

• Documentation of all of the following is required:        
  • appropriate diagnosis; and
  • for betamethasone/calcipotriene topical suspension, member is ≥ 18 years of age; and
  • for betamethasone/calcipotriene ointment, member is ≥ 12 years of age; and
  • medical necessity for the combination product instead of the commercially available separate agents. 

Capex

• Documentation of all of the following is required:        
  • diagnosis of scalp-related condition; and
  • inadequate response or adverse reaction to a topical corticosteroid of a similar or greater potency available without PA and used on the scalp.

Duobrii (halobetasol/tazarotene lotion)

• 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 one superpotent or potent topical corticosteroid available without PA; and
  • medical necessity for the combination product instead of the commercially available separate agents.