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Table 18: Cardiovascular Agents


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Drug Category: Cardiovascular Agents

Medication Class/Individual Agents: Cardiovascular Agents

I. Prior-Authorization Requirements

 Cardiovascular Agents – Aldosterone Receptor Antagonists

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

eplerenone Inspra test   BP, M90

Carospir

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the use of a suspension formulation as noted by one of the following:
      • member utilizes tube feeding (G-tube, J tube); or
      • member has a swallowing disorder or condition affecting ability to swallow; or
      • member is < 13 years of age.

Kerendia

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • concurrent therapy with an ACE-I or ARB; and
    • inadequate response or adverse reaction to one or contraindication to all of the following: Farxiga, Invokana, Jardiance, Steglatro; and
    • requested quantity ≤ one unit/day.
 
finerenone Kerendia PA  
spironolactone suspension Carospir PA  
spironolactone tablet Aldactone test   # , M90

 Cardiovascular Agents – Alpha Agonists / Centrally Acting Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

clonidine extended-release 0.17 mg tablet PA   A90

clonidine extended-release 0.17 mg tablet

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to clonidine immediate-release tablets; and
    • inadequate response or adverse reaction to two or contraindication to all other antihypertensive agents; and
    • appropriate dosing.

 

clonidine patch

  • Documentation of all of the following is required for a diagnosis of hypertension:
    • appropriate diagnosis; and
    • one of the following:
      • medical records documenting an inadequate response or adverse reaction to oral clonidine; or
      • member has a swallowing disorder or condition affecting ability to swallow; and
    • inadequate response or adverse reaction to two or contraindication to all other antihypertensive agents.
  • Documentation of all of the following is required for a diagnosis of ADHD:
    • appropriate diagnosis; and
    • one of the following:
      • medical records documenting an inadequate response (defined as > seven days of therapy) or adverse reaction to clonidine immediate-release; or
      • medical necessity for the transdermal formulation; and
    • inadequate response (defined as > seven days of therapy), adverse reaction, or contraindication to both of the following: an amphetamine product, a methylphenidate product.

 

In addition to individual drug PA criteria where applicable, some behavioral health medications are subject to additional polypharmacy and age limit restrictions (see below).

 
clonidine patch Catapres-TTS PA   A90
clonidine tablet PA   - < 3 years A90
guanfacine PA   - < 3 years A90
methyldopa test   M90

 Cardiovascular Agents – Alpha Blocking Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

doxazosin immediate-release Cardura test   # , M90

phenoxybenzamine

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • appropriate dosing; and
    • inadequate response or adverse reaction to one or contraindication to all selective α-1 blockers (prazosin, terazosin or doxazosin).
 
phenoxybenzamine PA   M90
prazosin Minipress test   # , M90
terazosin test   M90

 Cardiovascular Agents – Anti-Anginal Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

isosorbide dinitrate 40 mg tablet Isordil PA   BP, M90

Aspruzyo

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to one or contraindication to all of the following: beta-blockers, calcium channel blockers, nitratesranolazine tablets; and
    • one of the following:
      • member has severe dysphagia and is currently utilizing only formulations that can easily be swallowed (e.g., solutions, suspensions, films, or dispersible tablets); or
      • member utilizes tube feeding; or
      • medical necessity for the requested formulation instead of ranolazine; and
    • appropriate dosing; and
    • requested quantity is ≤ two packets/day.

 

Gonitro, nitroglycerin lingual spray

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to nitroglycerin sublingual tablets.

isosorbide dinitrate 40mg

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • requested dose is > 40 mg/dose; and
    • medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to two units of isosorbide dinitrate 20 mg tablet.
 
isosorbide dinitrate 5 mg, 10 mg, 20 mg, 30 mg tablet Isordil test   # , M90
isosorbide mononitrate test   M90
nitroglycerin 2% ointment Nitro-Bid test   # , A90
nitroglycerin lingual spray Nitrolingual PA   BP, A90
nitroglycerin patch Nitro-Dur test   # , M90
nitroglycerin sublingual powder Gonitro PA  
nitroglycerin sublingual tablet Nitrostat test   # , A90
ranolazine extended-release granules Aspruzyo PA  
ranolazine extended-release tablet Ranexa test   # , A90

 Cardiovascular Agents – Antiarrhythmics

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

amiodarone injection test   MB

quinidine gluconate extended-release

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to quinidine sulfate.

SmartPA: Claims for quinidine gluconate extended-release will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for quinidine sulfate.†

 
amiodarone tablet test   M90
disopyramide controlled-release Norpace CR test  
disopyramide immediate-release Norpace test   # , A90
dofetilide Tikosyn test   # , M90
dronedarone Multaq test   A90
flecainide test   M90
mexiletine test   M90
propafenone extended-release Rythmol SR test   # , M90
propafenone immediate-release test   M90
quinidine gluconate extended-release PA   A90
quinidine sulfate test   M90

 Cardiovascular Agents – Beta-Adrenergic Blocking Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

acebutolol test   M90

carvedilol extended-release

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction or contraindication to carvedilol immediate-release.

 

Hemangeol

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the use of a solution formulation as noted by one of the following:
      • member utilizes tube feeding (G-tube, J-tube); or
      • member has a swallowing disorder or condition affecting ability to swallow; or
      • member is < 13 years of age.

 

Inderal XL, Innopran XL

  • Documentation of all of the following is required for a diagnosis of hypertension:
    • diagnosis of hypertension; and
    • inadequate response or adverse reaction to all of the following: a long-acting formulation of propranolol that is available without prior authorization, a beta-blocker, and one other antihypertensive agent. 
  • Documentation of all of the following is required for a diagnosis of migraine, angina, pulmonary hypertension, Raynaud’s syndrome:
    • diagnosis of migraine, angina, pulmonary hypertension, Raynaud’s syndrome; and
    • inadequate response or adverse reaction to a long-acting formulation of propranolol that is available without prior authorization.

 

Kapspargo

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the use of a capsule formulation as noted by one of the following:
      • member utilizes tube feeding (G-tube, J-tube); or
      • member has a swallowing disorder or condition affecting ability to swallow; or
      • member is < 13 years of age.

 

Sotylize

  • Documentation of all of the following is required:
    • diagnosis of life-threatening ventricular arrhythmias or highly symptomatic atrial fibrillation or atrial flutter; and
    • medical necessity for the use of a solution formulation as noted by one of the following:
      • member utilizes tube feeding (G-tube, J-tube); or
      • member has a swallowing disorder or condition affecting ability to swallow; or
      • member is < 13 years of age.
 
atenolol Tenormin test   # , M90
betaxolol tablet test   M90
bisoprolol test   M90
carvedilol Coreg test   # , M90
carvedilol extended-release Coreg CR PA   BP, M90
esmolol Brevibloc test   #
labetalol test   M90
metoprolol Lopressor test   # , M90
metoprolol extended-release capsule Kapspargo PA  
metoprolol extended-release tablet Toprol XL test   # , M90
nadolol Corgard test   # , M90
nebivolol Bystolic test   BP, M90
pindolol test   M90
propranolol extended-release Inderal LA test   # , M90
propranolol immediate-release test   M90
propranolol long-acting capsule Inderal XL PA  
propranolol long-acting capsule Innopran XL PA  
propranolol solution Hemangeol PA   M90
sotalol solution Sotylize PA  
sotalol tablet Betapace test   # , M90
timolol tablet test   M90

 Cardiovascular Agents – Calcium Channel Blocking Agents - Dihydropyridine

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

amlodipine Norvasc test   # , M90

Katerzia and Norliqva

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the use of a suspension formulation as noted by one of the following:
      • member utilizes tube feeding (G-tube, J-tube); or
      • member has a swallowing disorder or condition affecting ability to swallow; or
      • member is < 13 years of age.

 

levamlodipine

  • Documentation of all the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse drug reaction or contraindication to amlodipine; and
    • inadequate response or adverse drug reaction to one or contraindication to all other calcium channel blockers available without prior authorization.

nimodipine capsule and Nymalize > 21 days treatment/365 days

  • Documentation of all of the following is required:
    • appropriate diagnosis (subsequent episode of subarachnoid hemorrhage); and
    • appropriate dosing; and
    •  for solution formulation, medical necessity for the use of a solution formulation as noted by one of the following:
      • member utilizes tube feeding (G-tube, J-tube); or
      • member has a swallowing disorder or condition affecting ability to swallow.

 

isradipine, nicardipine capsules, nisoldipine

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to two or contraindication to all calcium channel blockers available without PA.

SmartPA: Claims for isradipine, nicardipine capsules, and nisoldipine will usually process at the pharmacy without a PA request if the member has MassHealth medical claims for an appropriate clinical indication (for example: hypertension, migraine, angina, pulmonary hypertension, or Raynaud’s phenomenon), and a history of paid MassHealth pharmacy claims for two calcium channel blockers available without PA.†

 
amlodipine solution Norliqva PA  
amlodipine suspension Katerzia PA  
felodipine extended-release test   M90
isradipine immediate-release PA   M90
levamlodipine PA   M90
nicardipine capsule PA   M90
nicardipine injection test  
nifedipine capsule test   M90
nifedipine extended-release Procardia XL test   # , M90
nifedipine tablet Adalat test   # , M90
nimodipine capsule PA   - > 21 days treatment/365 days
nimodipine oral solution Nymalize PA   - > 21 days treatment/365 days
nisoldipine Sular PA   M90

 Cardiovascular Agents – Calcium Channel Blocking Agents - Non-Dihydropyridine

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

diltiazem 120 mg, 180 mg, 240 mg, 300 mg-Cardizem CD Cardizem CD test   # , M90

Cardizem CD (diltiazem) 360 mg

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the 360 mg capsule instead of formulations available without prior authorization.
 
diltiazem 360 mg-Cardizem CD Cardizem CD PA   M90
diltiazem extended-release tablet Cardizem LA test   # , M90
diltiazem-Cardizem Cardizem test   # , M90
diltiazem-Tiazac ER Tiazac ER test   # , M90
verapamil capsule Verelan test   # , M90
verapamil extended-release Verelan PM test   # , M90
verapamil sustained-release Calan SR test   # , M90
verapamil tablet test   M90

 Cardiovascular Agents – Cardiac glycosides

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

digoxin Lanoxin test   # , M90

 Cardiovascular Agents – Combination Antihypertensives

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

aliskiren / hydrochlorothiazide Tekturna HCT test  

amlodipine/atorvastatin

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
      • one of the following:
        • inadequate response to ≥ 40 mg/day rosuvastatin for at least three months, adverse reaction or contraindication to rosuvastatin; or
        • clinical rationale for not using rosuvastatin; and
      • one of the following:
        • request is within quantity limits; or
        • medical necessity for the requested agent above quantity limits. 

SmartPA: Claims for amlodipine/atorvastatin at a quantity of ≤ one unit/day will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for 90 days out of the last 120 days of the requested agent, or has a history of paid MassHealth pharmacy claims for rosuvastatin at a dose of at least 40 mg for at least three months in all claims history.

 

amlodipine/olmesartan/hydrochlorothiazide, amlodipine/telmisartan, candesartan/hydrochlorothiazide, captopril/hydrochlorothiazide, trandolapril/verapamil

  • Documentation of one of the following is required:
    • stable dosing of each separate agent for at least three months; or
    • stability on the combination agent for at least three months; or
    • medical necessity for one agent in members with complex, multiple, comorbid conditions.

SmartPA: Claims will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for at least 90 days (on separate agents or combination agents) out of the last 120 days.†

    

Concurrent therapy – ACE inhibitor, ARB, and/or direct renin inhibitor

  • Requests for concurrent therapy with two or more renin angiotensin system agents are evaluated on a case-by-case basis.
 
amiloride / hydrochlorothiazide test   M90
amlodipine / atorvastatin Caduet PA   M90
amlodipine / benazepril Lotrel test   # , M90
amlodipine / olmesartan Azor test   # , M90
amlodipine / olmesartan / hydrochlorothiazide Tribenzor PA   M90
amlodipine / telmisartan Twynsta PA   M90
amlodipine / valsartan Exforge test   # , M90
amlodipine / valsartan / hydrochlorothiazide Exforge HCT test   # , M90
atenolol / chlorthalidone Tenoretic test   # , M90
azilsartan / chlorthalidone Edarbyclor test  
benazepril / hydrochlorothiazide Lotensin HCT test   # , M90
bisoprolol / hydrochlorothiazide Ziac test   # , M90
candesartan / hydrochlorothiazide Atacand HCT PA   M90
captopril / hydrochlorothiazide PA   M90
enalapril / hydrochlorothiazide Vaseretic test   # , M90
fosinopril / hydrochlorothiazide test   M90
hydrochlorothiazide / triamterene Maxzide test   # , M90
hydrochlorothiazide / triamterene test   M90
irbesartan / hydrochlorothiazide Avalide test   # , M90
isosorbide dinitrate / hydralazine Bidil test   # , M90
lisinopril / hydrochlorothiazide Zestoretic test   # , M90
losartan / hydrochlorothiazide Hyzaar test   # , M90
methyldopa / hydrochlorothiazide test   M90
metoprolol / hydrochlorothiazide test   M90
olmesartan / hydrochlorothiazide Benicar HCT test   # , M90
propranolol / hydrochlorothiazide test   M90
quinapril / hydrochlorothiazide Accuretic test   # , M90
spironolactone / hydrochlorothiazide Aldactazide test   # , M90
telmisartan / hydrochlorothiazide Micardis HCT test   # , M90
trandolapril / verapamil PA   M90
valsartan / hydrochlorothiazide Diovan HCT test   # , M90

 Cardiovascular Agents – Direct Vasodilators

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

hydralazine test   M90

    

 
minoxidil test   M90

 Cardiovascular Agents – Diuretics

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

amiloride test   M90

ethacrynic acid tablet

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to one or contraindication to all of the following: furosemide, bumetanide, torsemide.

SmartPA: Claims for ethacrynic acid tablet will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for furosemide, bumetanide or torsemide.†

 

Furoscix

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • prescriber is a specialist (e.g., cardiologist, heart failure specialist) or consultation notes from a specialist are provided; and
    • member is on background loop diuretic therapy with 40 to 160 mg of oral furosemide equivalents; and
    • treatment with oral diuretics will be discontinued until transitioned back to oral diuretic maintenance therapy; and
    • requested quantity is ≤ eight kits.

 

triamterene

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to one or contraindication to both of the following: amiloride, spironolactone.

SmartPA: Claims for triamterene will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for amiloride or spironolactone.†

 
bumetanide test   M90
chlorothiazide Diuril test   # , M90
chlorthalidone Thalitone test  
chlorthalidone test   M90
ethacrynic acid tablet Edecrin PA   M90
furosemide on-body infusor Furoscix PA  
furosemide tablet, solution, injection Lasix test   # , M90
hydrochlorothiazide test   M90
indapamide test   M90
metolazone test   M90
torsemide test   M90
triamterene PA   M90

 Cardiovascular Agents – Ganglionic Blocking Agent

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

mecamylamine Vecamyl PA  

Vecamyl

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • prescriber is a cardiologist or nephrologist, or consultation notes from a cardiologist or nephrologist are provided; and
    • causes of secondary hypertension have been ruled out or addressed; and
    • adverse reaction, inadequate response or contraindication to one agent from all of the following classes:
      • aldosterone antagonists; and
      • alpha agonists; and
      • angiotensin converting enzyme (ACE) inhibitors; and
      • angiotensin II receptor blockers (ARB); and
      • beta blockers; and
      • calcium channel blockers; and
      • diuretics (thiazide or loop).
 

 Cardiovascular Agents – HCN Channel Inhibitor

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

ivabradine Corlanor PA  

Corlanor

  • Documentation of all of the following is required for a diagnosis of chronic heart failure with LVEF ≤ 35%:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • prescriber is a cardiologist or consultation notes from a cardiologist are provided; and
    • member has a resting heart rate of ≥ 70 beats per minute (bpm); and
    • one of the following:
      • member is currently receiving a beta-blocker (carvedilol, metoprolol succinate or bisoprolol) at maximally tolerated doses; or
      • adverse reaction to one beta-blocker or contraindication to all beta-blockers;  and
    • one of the following:
      • member is currently receiving standard of care therapy with an ACE inhibitor, ARB, or angiotensin-receptor neprilysin inhibitor (ARNI); or
      • contraindication to all ACE inhibitors, ARBs and ARNIs; and
    • for tablet formulation, requested quantity is ≤ two tablets/day; and
    • for solution formulation, medical necessity for the use of the solution formulation as noted by one of the following:
      • requested dose is < 2.5 mg; or
      • member utilizes tube feeding (G-tube, J-tube); or
      • member has a swallowing disorder or condition affecting ability to swallow.

 

  • Documentation of all of the following is required for a diagnosis of heart failure due to dilated cardiomyopathy:
    • appropriate diagnosis; and
    • member is ≥ six months of age and < 18 years of age; and
    • member has normal sinus rhythm with an elevated heart rate; and
    • prescriber is a cardiologist or consultation notes from a cardiologist are provided; and
    • one of the following:
      • member is currently receiving a beta-blocker (carvedilol, metoprolol succinate or bisoprolol) at maximally tolerated doses; or
      • adverse reaction to one beta-blocker or contraindication to all beta-blockers;  and
    • one of the following:
      • member is currently receiving standard of care therapy with an ACE inhibitor, ARB, or angiotensin-receptor neprilysin inhibitor (ARNI); or
      • adverse reaction to one or contraindication to all ACE inhibitors, ARBs and ARNIs; and
    • for tablet formulation, requested quantity is ≤ two tablets/day; and
    • for solution formulation, medical necessity for use of the solution formulation as noted by one of the following:
      • member is < 13 years of age; or
      • requested dose is < 2.5 mg; or
      • member utilizes tube feeing (G-tube, J-tube); or
      • member has a swallowing disorder or condition affecting ability to swallow.

 

  • Documentation of all of the following is required for a diagnosis of postural tachycardia syndrome (POTS):
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to two or contraindication to all of the following: a beta blocker, droxidopa, fludrocortisone, midodrine, pyridostigmine; and
    • requested quantity is ≤ two tablets/day.
 

 Cardiovascular Agents – Not Otherwise Classified

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

droxidopa Northera PA   A90

Camzyos

  • Documentation of all of the following is required:
    • diagnosis of NYHA class II-III obstructive hypertrophic cardiomyopathy; and
    • prescriber is a cardiologist or consultation notes from a cardiologist are provided; and
    • inadequate response or adverse reaction to one or contraindication to all beta blockers; and
    • inadequate response or adverse reaction to one or contraindication to both of the following: diltiazem, verapamil; and
    • inadequate response, adverse reaction, or contraindication to disopyramide; and
    • appropriate dosing; and
    • requested quantity is ≤ one tablet/day
  • For recertification, documentation of positive response to therapy is required.

droxidopa

  • Documentation of all of the following is required:
    • diagnosis of symptomatic neurogenic orthostatic hypotension (NOH) caused by one of the following:
      • primary autonomic failure; or
      • dopamine beta-hydroxylase deficiency; or
      • non-diabetic autonomic neuropathy (NDAN); and
    • inadequate response or adverse reaction to one or contraindication to both of the following: atomoxetine, midodrine; and
    • inadequate response, adverse reaction, or contraindication to fludrocortisone.
  • For recertification, medical records documenting positive response to therapy (e.g., increased standing blood pressure following treatment with droxidopa without increasing supine blood pressure, improvement on the Orthostatic Hypotension Questionnaire or Orthostatic Hypotension Symptom Assessment score for dizziness/lightheadedness, decreased symptoms of dizziness, lightheadedness, fainting episodes) is required.

 

 
mavacamten Camzyos PA  
metyrosine Demser test   BP

 Cardiovascular Agents – Renin Angiotensin System Antagonists - Angiotensin II Receptor Antagonists (ARBS)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

azilsartan Edarbi test  

candesartan, eprosartan

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to both of the following: losartan, irbesartan or valsartan.

SmartPA: Claims for candesartan and eprosartan will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for at least 90 days out of the last 120 days, or if the member has a history of paid MassHealth pharmacy claims for losartan and irbesartan or valsartan.†

 

valsartan solution

Documentation of all of the following is required:

  • appropriate diagnosis; and
  • medical necessity for the use of the solution formulation as noted by one of the following:
    • member utilizes tube feeding (G-tube/J-tube); or
    • member has a swallowing disorder or condition affecting ability to swallow; or
    • member is < 13 years of age.

 

Concurrent therapy – ACE inhibitor, ARB, and/or direct renin inhibitor

Requests for concurrent therapy with two or more renin angiotensin system agents are evaluated on a case-by-case basis.

 
candesartan Atacand PA   M90
eprosartan PA   M90
irbesartan Avapro test   # , M90
losartan Cozaar test   # , M90
olmesartan Benicar test   # , M90
telmisartan Micardis test   # , M90
valsartan solution PA   M90
valsartan tablet Diovan test   # , M90

 Cardiovascular Agents – Renin Angiotensin System Antagonists - Angiotensin-Converting Enzyme (ACE) Inhibitors

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

benazepril Lotensin test   # , M90

captopril

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to two ACE inhibitors available without PA.

SmartPA: Claims for captopril will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for at least 90 days out of the last 120 days, or if the member has MassHealth medical claims for hypertension, heart failure, left ventricular dysfunction, myocardial infarction, or diabetic nephropathy and a history of paid MassHealth pharmacy claims for two ACE inhibitors that are available without PA.†

 

Epaned and Qbrelis

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the use of a solution formulation as noted by one of the following:
      • member utilizes tube feeding (G-tube/J-tube); or
      • member has a swallowing disorder or condition affecting ability to swallow; or
      • member is < 13 years of age

 

Concurrent therapy – ACE inhibitor, ARB, and/or direct renin inhibitor

Requests for concurrent therapy with two or more renin angiotensin system agents are evaluated on a case-by-case basis.

 
captopril PA   M90
enalapril Vasotec test   # , M90
enalapril solution Epaned PA   M90
fosinopril test   M90
lisinopril Zestril test   # , M90
lisinopril test   M90
lisinopril solution Qbrelis PA  
moexipril test   M90
perindopril test   M90
quinapril Accupril test   # , M90
ramipril Altace test   # , M90
trandolapril test   M90

 Cardiovascular Agents – Renin Angiotensin System Antagonists - Direct Renin Inhibitors

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

aliskiren Tekturna PA   BP, M90

aliskiren

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to both of the following: ARB and ACE inhibitor.

 

Concurrent therapy – ACE inhibitor, ARB, and/or direct renin inhibitor

Requests for concurrent therapy with two or more renin angiotensin system agents are evaluated on a case-by-case basis.

 

 Cardiovascular Agents – Renin Angiotensin System Antagonists – Angiotensin Receptor Neprilysin Inhibitor (ARNI)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

sacubitril / valsartan Entresto PA  

Entresto

  • Documentation of all the following is required:
    • diagnosis of chronic heart failure; and
    • member is ≥ one year of age.

SmartPA: Claims for Entresto will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for at least 90 days out of the last 120 days or if the member is ≥ one year of age and has a history of MassHealth medical claims for a diagnosis of chronic heart failure.†

 

 Cardiovascular Agents – Soluble Guanylate Cyclase (sGC) Stimulator

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

vericiguat Verquvo PA  

Verquvo

  • Documentation of all of the following is required:
    • diagnosis of chronic heart failure NYHA Class II to IV; and
    • left ventricular ejection fraction (LVEF) < 45%; and
    • member is ≥ 18 years of age; and
    • one of the following:
      • member has had a hospitalization related to heart failure within the last six months; or
      • member has received outpatient IV diuretic therapy for heart failure within the last three months; and
    • prescriber is a cardiologist or consultation notes from a cardiologist are provided; and
    • one of the following:
      • member has remained symptomatic despite receiving standard of care therapy with an ACEI/ARB/ARNI in combination with a β-blocker (carvedilol, metoprolol succinate or bisoprolol); or
      • adverse reaction to one ACE inhibitor, ARB, ARNI and/or beta blocker, or contraindication to all ACE inhibitors, ARBs, ARNIs and beta blockers; and
    • requested quantity is ≤ one unit/day.

 

 

 Cardiovascular Agents – Vasopressin Antagonist

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes

tolvaptan-Samsca Samsca PA   BP, A90

tolvaptan (generic Samsca)

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • member is currently stabilized on the requested agent; and
    • one of the following:
      • for 15 mg tablet, requested quantity is ≤ one unit/day; or
      • for 30 mg tablet, requested quantity is ≤ two units/day; or
      • clinical rationale for high dose.
 
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 
MB This drug is available through the health care professional who administers the drug or in an outpatient or inpatient hospital setting. MassHealth does not pay for this drug to be dispensed through the retail pharmacy. If listed, prior authorization does not apply through the hospital outpatient and inpatient settings. Please refer to 130 CMR 433.408 for prior authorization requirements for other health care professionals. Notwithstanding the above, this drug may be an exception to the unified pharmacy policy; please refer to respective MassHealth Accountable Care Partnership Plans (ACPPs) and Managed Care Organizations (MCOs) for prior authorization status and criteria, if applicable.
 
A90 Allowable 90-day supply. Dispensing in up to a 90-day supply is allowed. May not include all strengths or formulations. Quantity limits and other restrictions may apply.
 
M90 Mandatory 90-day supply. After dispensing up to a 30-day supply initial fill, dispensing in a 90-day supply is required. May not include all strengths or formulations. Quantity limits and other restrictions may also apply.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Angina pectoris
  • Arrhythmias, paroxysmal supraventricular tachycardia
  • Cardiac arrhythmias
  • Cardiovascular events risk reduction
  • Chronic kidney disease associated with type 2 diabetes (Kerendia)
  • Congestive heart failure
  • Congestive heart failure post MI
  • Coronary artery disease (stable or variant angina)
  • Diabetic nephropathy
  • Euvolemic hyponatremia (SIADH)
  • Heart failure
  • Hypertension
  • Hypertrophic subaortic stenosis
  • Hypervolemic hyponatremia (CHF)
  • Left ventricular dysfunction
  • Left ventricular dysfunction following MI
  • Migraine prophylaxis
  • Myocardial infarction
  • New York Heart Association (NYHA) class II-III obstructive hypertrophic cardiomyopathy (HCM) (Camzyos)
  • Pheochromocytoma
  • Post-myocardial infarction
  • Proliferating infantile hemangioma
  • Raynaud phenomenon
  • Reduction of stroke risk with left ventricular hypertrophy
  • Subarachnoid hemorrhage (nimodipine)

non-FDA-approved, for example:

  • Angina pectoris
  • Arrhythmias, paroxysmal supraventricular tachycardia
  • Attention deficit hyperactivity disorder (ADHD)
  • Cardiac arrhythmias
  • Postural tachycardia syndrome (POTS)

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

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III.  Evaluation Criteria for Approval

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.

Please see clinical criteria for agents requiring PA in the table above under the Clinical Notes section.


In addition to individual drug PA criteria where applicable, some behavioral health medications are subject to additional polypharmacy and age limit restrictions.

  

Behavioral Health Medication Polypharmacy (pharmacy claims for any combination of four or more behavioral health medications [i.e., alpha2 agonists, antidepressants, antipsychotics, armodafinil, atomoxetine, benzodiazepines, buspirone, cerebral stimulants, donepezil, hypnotic agents, memantine, modafinil, mood stabilizers (agents considered to be used only for seizure diagnoses are not included), naltrexone, and viloxazine] within a 45-day period) for members < 18 years of age

  • For all requests, individual drug PA criteria must be met first where applicable.
  • For regimens including ≤ two mood stabilizers (also includes regimens that do not include a mood stabilizer), documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnoses; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided.

 

  • For regimens including ≥ three mood stabilizers, documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnoses; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; and
      • one of the following:
        • member has a seizure diagnosis only; or
        • member has an appropriate psychiatric diagnosis, with or without seizure diagnosis, and one of the following:
          • cross-titration/taper of mood stabilizer therapy; or
          • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate; or
        • member has a diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain), with or without seizure diagnosis, and that other clinically appropriate therapies have been tried and failed; therefore, multiple mood stabilizers are needed; or
        • member has psychiatric and comorbid diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain), with or without seizure diagnosis and that other clinically relevant therapies have been tried and failed; therefore, multiple mood stabilizers are needed, and one of the following:
          • cross-titration/taper of mood stabilizer therapy; or
          • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate.

 

Alpha Agonist for members < three years of age

  • For all requests, individual drug PA criteria must be met first where applicable.  
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
      • member has a cardiovascular diagnosis only; or
    • all of the following:
      • appropriate diagnosis; and
      • treatment plan including names of current alpha agonist(s) and corresponding diagnoses; and
      • clinical rationale for use of alpha agonist in member < three years of age.

 

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.


Original Effective Date: 04/2003

Last Revised Date: 04/2023


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Last updated 11/27/23

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