Carospir

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • medical necessity for the use of a suspension formulation.

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
    • clinical rationale for transdermal formulation; 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
  • clinical rationale for use over 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.

ranolazine

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • one of the following:
    • inadequate response or adverse reaction to two of the following: beta-blockers, nitrates, calcium channel blockers; or
    • contraindication to beta-blockers, nitrates, and calcium channel blockers.

SmartPA: Claims for ranolazine 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 angina and a history of paid MassHealth pharmacy claims for two of the following classes: beta-blockers, nitrates, and calcium channel blockers.†

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
  • medical necessity for carvedilol extended-release over carvedilol immediate-release.

Hemangeol

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • medical necessity for the use of the solution dosage formulation.

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 a long-acting generic propranolol formulation; and
  • inadequate response or adverse reaction to two other antihypertensive agents, at least one of which is a beta-blocker.
• 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 generic propranolol formulation.

Kapspargo

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • one of the following:
    • adverse reaction or inadequate response to metoprolol extended-release tablet; or
    • medical necessity for the use of a capsule formulation.

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 the solution formulation.

Katerzia

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • medical necessity for the use of a suspension formulation.

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
  • dose and frequency are appropriate; and
  • if the request is for solution, medical necessity for the use of a solution formulation.

nisoldipine

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • one of the following:
    • adverse reaction or inadequate response to two calcium channel blockers (CCB) that do not require PA; or
    • clinical rationale why a CCB that does not require PA has not been tried.

SmartPA: Claims for 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 generic non-PA CCB.†

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.†

Bidil

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • compelling clinical rationale as to why the doses available in the combination product would provide a therapeutic advantage over the doses in the commercially available separate agents.

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 of the following is required:
  • appropriate diagnosis; and
  • member is ≥ one year old.

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 consult with a cardiologist or nephrologist is 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 old; and
  • prescriber is a cardiologist, or consult with a cardiologist is 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 a beta-blocker; or
    • clinical rationale why a beta-blocker cannot be used; and
  • one of the following:
    • member had received standard of care therapy with an ACE inhibitor, ARB, or angiotensin-receptor neprilysin inhibitor (ARNI) in combination with a beta-blocker; or
    • clinical rationale why member cannot receive standard of care therapy with an ACE inhibitor, ARB, or ARNI in combination with a beta-blocker; and
  • if the request is for tablets, request is within quantity limit of two units/day; and
  • if the request is for solution and the requested dose is ≥ 2.5 mg, medical necessity for the use of a solution formulation.
• 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 old and < 18 years old; and
  • member has normal sinus rhythm with an elevated heart rate; and
  • requested medication will be used as add-on to standard of care therapy; and
  • prescriber is a cardiologist, or consult with a cardiologist is provided; and
  • if the request is for solution, one of the following:
    • member is < 13 years old; or
    • requested dose is < 2.5 mg; or
    • medical necessity for the use of a solution formulation.

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 losartan; and
  • inadequate response, adverse reaction, or contraindication to 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 different ACE inhibitors.

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 generic ACE inhibitors that are covered 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.

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 an ACE inhibitor and an ARB.

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.

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 regarding the diagnosis and treatment recommendations 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
    • clinical rationale why member cannot receive standard therapy with an ACEI/ARB/ARNI in combination with a β-blocker; 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.