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
  • documentation of 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.

clonidine patch

• Documentation of all of the following is required:
  • 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 other antihypertensive agents.

clonidine powder

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

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

phenoxybenzamine

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

Gonitro, nitroglycerin lingual spray, Nitromist

• 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 per dose; and
  • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to two units of isosorbide dinitrate 20 mg tablet.

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.†

carvedilol extended-release

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

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
  • adverse reaction or inadequate response to all of the following: a long-acting formulation of propranolol that does not require a 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
  • adverse reaction (not class specific) or inadequate response to a long-acting formulation of propranolol.

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.

Katerzia

• 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
  • one of the following:
    • inadequate response or adverse drug reaction to one other calcium channel blocker available without prior authorization; or
    • contraindication to all 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
  • if the request is for solution, 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 calcium channel blockers available without PA 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 that do not require PA.†

Cardizem CD (diltiazem) 360 mg

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • clinical rationale for the use of the 360 mg strength.

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 patients 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 90 days (on separate agents or combination agents) in the past 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.

ethacrynic acid tablet

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

triamterene

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

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.†

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).

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
  • if the request is for tablets, request does not exceed two tablets/day; and
  • if the request is 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
  • if the request is for tablet formulation, request does not exceed two tablets/day; and
  • if the request is for solution, 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.

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, adverse reaction, or contraindication to 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.

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 will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for 90 days in the past 120 days of the requested agent, or if the member has a history of paid MassHealth pharmacy claims for losartan and irbesartan or valsartan.†

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

• 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 for 90 days in the past 120 days of the requested agent, 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.

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.

Entresto

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

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 out of the last 120 days of the requested agent or if the member is ≥ one year of age and has a history of MassHealth medical claims for a diagnosis of chronic heart failure.†

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
  • request does not exceed one unit/day.

tolvaptan (generic Samsca)

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years old; and
  • member is currently stabilized on the requested agent; and
  • one of the following:
    • request is within quantity limits of one unit/day for 15 mg tablets or two units/day for 30 mg tablets; or
    • clinical rationale for high dose.