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This is a listing of all of the drugs covered by MassHealth. Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for.

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MassHealth Drug List table
Drug - Brand Name (Generic Name) Class
Symjepi (epinephrine injection)drugId:7105 ADRENERGICS
Sublocade (buprenorphine extended-release injection)drugId:6524 - PA ALCOHOL AND DRUG CESSATION AGENT
Suboxone (buprenorphine / naloxone film)drugId:2049 BP PD - PA > 32 mg/day ALCOHOL AND DRUG CESSATION AGENT
Suboxone (buprenorphine / naloxone film)drugId:2050 BP PD - PA > 90 days (> 24 mg/day and ≤ 32 mg/day) ALCOHOL AND DRUG CESSATION AGENT
Suboxone (buprenorphine / naloxone film ≤ 24 mg/day)drugId:2085 BP PD ALCOHOL AND DRUG CESSATION AGENT
spironolactone suspensiondrugId:6280 - PA ALDOSTERONE ANTAGONISTS
spironolactone tabletdrugId:1892 ALDOSTERONE ANTAGONISTS
Savella (milnacipran)drugId:1358 - PA ANALGESICS
Sensorcaine # (bupivacaine) ANESTHETICS
Synera (lidocaine / tetracaine)drugId:1075 - PA > 4 patches / month ANESTHETICS
sucralfate suspension BP ANTACIDS
sucralfate tablet ANTACIDS
secnidazoledrugId:6523 - PA ANTIBIOTICS
SilvadenedrugId:1850 # (silver sulfadiazine-Silvadene)drugId:1850 ANTIBIOTICS
silver sulfadiazine-SilvadenedrugId:1850 ANTIBIOTICS
silver sulfadiazine-SSDdrugId:2534 ANTIBIOTICS
silver sulfadiazine-ThermazenedrugId:1852 ANTIBIOTICS
Sivextro (tedizolid injection)drugId:4636 - PA ANTIBIOTICS
Sivextro (tedizolid tablet)drugId:4635 - PA ANTIBIOTICS
Solodyn (minocycline extended-release 55 mg, 65 mg, 80 mg, 105 mg, 115 mg tablet)drugId:1364 BP ANTIBIOTICS
Solosec (secnidazole)drugId:6523 - PA ANTIBIOTICS
SSDdrugId:2534 # (silver sulfadiazine-SSD)drugId:2534 ANTIBIOTICS
streptomycindrugId:2496 ANTIBIOTICS
sulfadiazinedrugId:1906 ANTIBIOTICS
sulfamethoxazole / trimethoprim injectiondrugId:5661 ANTIBIOTICS
sulfamethoxazole / trimethoprim suspensiondrugId:5133 ANTIBIOTICS
sulfamethoxazole / trimethoprim tabletdrugId:1907 ANTIBIOTICS
SulfamylondrugId:1113 # (mafenide)drugId:1113 ANTIBIOTICS
sulfanilamidedrugId:1909 ANTIBIOTICS
SulfatrimdrugId:5133 # (sulfamethoxazole / trimethoprim suspension)drugId:5133 ANTIBIOTICS
Suprax (cefixime)drugId:196 - PA ANTIBIOTICS
Synercid (dalfopristin / quinupristin)drugId:2037 - PA ANTIBIOTICS
Savaysa (edoxaban)drugId:4795 - PA ANTICOAGULANTS
Sabril (vigabatrin) BP - PA; See Table 20drugId:1802; See Table 71drugId:4481 ANTICONVULSANTS
Spritam (levetiracetam tablet for oral suspension) - PA; See Table 20drugId:5397; See Table 71drugId:5398 ANTICONVULSANTS
stiripentol - PA; See Table 20drugId:7132; See Table 71drugId:7133 ANTICONVULSANTS
Sympazan (clobazam film) - PA; See Table 20drugId:7106; See Table 71drugId:7107 ANTICONVULSANTS
Sarafem (fluoxetine 20 mg tablet for premenstrual dysphoric disorder) - PA; See Table 17drugId:2589; See Table 71drugId:3741 ANTIDEPRESSANTS
Sarafem # (fluoxetine 10 mg tablet for premenstrual dysphoric disorder) - PA < 6 years; See Table 17drugId:881; See Table 71drugId:3740 ANTIDEPRESSANTS
selegiline transdermal patch - PA; See Table 17drugId:1840; See Table 71drugId:3560 ANTIDEPRESSANTS
sertraline - PA < 6 years; See Table 17drugId:1845; See Table 71drugId:3820 ANTIDEPRESSANTS
Spravato (esketamine) - PA; See Table 17drugId:7138; See Table 71drugId:7139 ANTIDEPRESSANTS
Surmontil # (trimipramine) - PA < 6 years; See Table 17drugId:1765; See Table 71drugId:4160 ANTIDEPRESSANTS
Symbyax (olanzapine / fluoxetine) - PA; See Table 17drugId:2058; See Table 24drugId:1279; See Table 71drugId:4264 ANTIDEPRESSANTS
Sancuso (granisetron transdermal system)drugId:685 - PA ANTIEMETICS
scopolamine transdermal patchdrugId:1835 BP - PA ANTIEMETICS
Sustol (granisetron extended-release injection)drugId:5767 - PA > 2 units/28 days ANTIEMETICS
Syndros (dronabinol solution)drugId:6361 - PA ANTIEMETICS
Sklice (ivermectin lotion)drugId:2584 - PA ANTIPARASITICS
spinosaddrugId:2239 - PA ANTIPARASITICS
StromectoldrugId:989 # (ivermectin tablet)drugId:989 ANTIPARASITICS
safinamidedrugId:6185 - PA ANTIPARKINSON
selegiline capsule, tabletdrugId:2378 ANTIPARKINSON
selegiline orally disintegrating tabletdrugId:1839 - PA ANTIPARKINSON
SinemetdrugId:175 # (carbidopa / levodopa tablet)drugId:175 ANTIPARKINSON
Sinemet CRdrugId:1997 # (carbidopa / levodopa extended-release tablet)drugId:1997 ANTIPARKINSON
Stalevo (carbidopa / levodopa / entacapone)drugId:176 - PA ANTIPARKINSON
Saphris (asenapine) - PA; See Table 24drugId:97; See Table 71drugId:4260 ANTIPSYCHOTIC
Seroquel # (quetiapine) - PA < 6 years and PA > 90 units/month; See Table 24drugId:1618; See Table 71drugId:4293 ANTIPSYCHOTIC
Seroquel XR # (quetiapine extended-release 150 mg, 200 mg) - PA < 6 years and PA > 30 units/month; See Table 24drugId:1617; See Table 71drugId:4294 ANTIPSYCHOTIC
Seroquel XR # (quetiapine extended-release 50 mg, 300 mg and 400 mg) - PA < 6 years and PA > 60 units/month; See Table 24drugId:1616; See Table 71drugId:4295 ANTIPSYCHOTIC
saquinavirdrugId:1832 ANTIVIRALS
Selzentry (maraviroc)drugId:1119 - PA ANTIVIRALS
sinecatechinsdrugId:1856 - PA ANTIVIRALS
Sitavig (acyclovir buccal tablet)drugId:2945 - PA ANTIVIRALS
sofosbuvir / velpatasvir / voxilaprevirdrugId:6364 PD - PA ANTIVIRALS
sofosbuvir / velpatasvirdrugId:5540 PD - PA ANTIVIRALS
sofosbuvirdrugId:2879 - PA ANTIVIRALS
Sovaldi (sofosbuvir)drugId:2879 - PA ANTIVIRALS
stavudinedrugId:1894 ANTIVIRALS
Stribild (elvitegravir / cobicistat / emtricitabine / tenofovir disoproxil fumarate)drugId:2648 ANTIVIRALS
Sustiva (efavirenz)drugId:590 BP ANTIVIRALS
Sylatron (peginterferon alfa-2b-Sylatron) ANTIVIRALS
Symfi (efavirenz / lamivudine / tenofovir disoproxil fumarate)drugId:6782 - PA ANTIVIRALS
Symfi Lo (efavirenz / lamivudine / tenofovir disoproxil fumarate)drugId:6783 - PA ANTIVIRALS
Symtuza (darunavir / cobicistat / emtricitabine / tenofovir alafenamide)drugId:6822 - PA ANTIVIRALS
Synagis (palivizumab)drugId:1472 - PA ANTIVIRALS
secobarbitaldrugId:1837 BARBITURATES
Seconal (secobarbital)drugId:1837 BARBITURATES
Shingrix (zoster vaccine recombinant, adjuvanted)drugId:6407 - PA < 50 years BIOLOGICAL
siltuximabdrugId:4540 - PA BIOLOGICAL
Simulect (basiliximab)drugId:2382 BIOLOGICAL
Soliris (eculizumab)drugId:589 - PA BIOLOGICAL
Spinraza (nusinersen)drugId:6020 - PA BIOLOGICAL
Stamaril (yellow fever vaccine, live)drugId:6106 BIOLOGICAL
Sylvant (siltuximab)drugId:4540 - PA BIOLOGICAL
salmeteroldrugId:1829 - PA BRONCHODILATORS
Seebri (glycopyrrolate inhalation powder)drugId:5393 - PA > 1 inhaler/month BRONCHODILATORS
Serevent (salmeterol)drugId:1829 - PA BRONCHODILATORS
Singulair (montelukast granules)drugId:5129 - PA BRONCHODILATORS
SingulairdrugId:1383 # (montelukast tablet, chewable tablet)drugId:1383 BRONCHODILATORS
Spiriva Handihaler (tiotropium inhalation powder)drugId:1708 - PA > 30 units/month BRONCHODILATORS
Spiriva Respimat (tiotropium inhalation solution)drugId:4640 - PA > 1 inhaler/month BRONCHODILATORS
Stiolto (tiotropium / olodaterol)drugId:5112 - PA BRONCHODILATORS
Striverdi (olodaterol)drugId:4641 - PA BRONCHODILATORS
Symbicort (budesonide / formoterol)drugId:383 - PA BRONCHODILATORS
Sensipar (cinacalcet) BP CALCIMIMETIC
sacubitril / valsartandrugId:5125 - PA CARDIOVASCULAR
selexipagdrugId:5401 - PA CARDIOVASCULAR
sildenafil 20 mg tabletdrugId:1848 - PA CARDIOVASCULAR
sildenafil oral suspensiondrugId:4793 BP - PA CARDIOVASCULAR
sotalol solutiondrugId:4913 - PA CARDIOVASCULAR
sotalol tabletdrugId:1891 CARDIOVASCULAR
Sotradecol (tetradecyl sulfate injection)drugId:2495 - PA CARDIOVASCULAR
Sotylize (sotalol solution)drugId:4913 - PA CARDIOVASCULAR
spironolactone / hydrochlorothiazidedrugId:1893 CARDIOVASCULAR
Sular (nisoldipine)drugId:1219 - PA CARDIOVASCULAR
sodium polystyrene sulfonatedrugId:1874 CHELATING AGENT
sodium zirconium cyclosilicatedrugId:6905 - PA > 30 units/month CHELATING AGENT
Syprine (trientine) BP CHELATING AGENT
samarium Sm 153 lexidronam ^ CHEMOTHERAPY
sipuleucel-TdrugId:2288 ^ - PA CHEMOTHERAPY
Solaraze (diclofenac 3% gel)drugId:508 - PA CHEMOTHERAPY
Soltamox (tamoxifen solution)drugId:4980 - PA CHEMOTHERAPY
sonidegibdrugId:5284 - PA CHEMOTHERAPY
sorafenibdrugId:1890 - PA CHEMOTHERAPY
Sprycel (dasatinib)drugId:331 CHEMOTHERAPY
Stivarga (regorafenib)drugId:2646 - PA CHEMOTHERAPY
streptozocindrugId:2700 CHEMOTHERAPY
sunitinibdrugId:1917 - PA CHEMOTHERAPY
Sutent (sunitinib)drugId:1917 - PA CHEMOTHERAPY
Synribo (omacetaxine mepesuccinate)drugId:2659 - PA CHEMOTHERAPY
simple syrup * COMPOUNDING AGENT
Symproic (naldemedine)drugId:6619 - PA CONSTIPATION AGENTS
Safyral # (ethinyl estradiol / drospirenone / levomefolate-Safyral) CONTRACEPTIVES
Seasonique # (levonorgestrel / ethinyl estradiol-Seasonique) CONTRACEPTIVES
Skyla (levonorgestrel-releasing intrauterine system 13.5 mg) CONTRACEPTIVES
Slynd (drospirenone) CONTRACEPTIVES
Symdeko (tezacaftor / ivacaftor)drugId:6540 - PA CYSTIC FIBROSIS AGENTS
Semprex-D (acrivastine / pseudoephedrine)drugId:1608 - PA DECONGESTANT
salicylic aciddrugId:1827 o DERMATOLOGICAL
selenium sulfide * DERMATOLOGICAL
Soolantra (ivermectin cream)drugId:4813 - PA DERMATOLOGICAL
SoriatanedrugId:153 # (acitretin)drugId:153 DERMATOLOGICAL
Sorilux (calcipotriene foam)drugId:2560 - PA DERMATOLOGICAL
sulfacetamidedrugId:1899 - PA ≥ 22 years DERMATOLOGICAL
saxagliptindrugId:1834 DIABETIC AGENTS
saxagliptin / metformin extended-releasedrugId:2103 DIABETIC AGENTS
Segluromet (ertugliflozin / metformin)drugId:6616 - PA DIABETIC AGENTS
semaglutidedrugId:6613 - PA DIABETIC AGENTS
sitagliptindrugId:1858 DIABETIC AGENTS
sitagliptin / metformindrugId:1859 DIABETIC AGENTS
sitagliptin / metformin extended-releasedrugId:2485 DIABETIC AGENTS
Soliqua (insulin glargine / lixisenatide)drugId:5766 - PA DIABETIC AGENTS
StarlixdrugId:1178 # (nateglinide)drugId:1178 DIABETIC AGENTS
Steglatro (ertugliflozin)drugId:6617 - PA DIABETIC AGENTS
Steglujan (ertugliflozin / sitagliptin)drugId:6618 - PA DIABETIC AGENTS
Symlin (pramlintide)drugId:1570 - PA DIABETIC AGENTS
Synjardy (empagliflozin / metformin)drugId:5113 - PA DIABETIC AGENTS
Synjardy XR (empagliflozin / metformin extended-release)drugId:6107 - PA DIABETIC AGENTS
sevelamer hydrochloride BP ELECTROLYTES AND NUTRIENTS
sodium chloride for inhalation * - Non-Drug Product ELECTROLYTES AND NUTRIENTS
sodium chloride solution ELECTROLYTES AND NUTRIENTS
sodium chloride tablet * ELECTROLYTES AND NUTRIENTS
sodium citrate / citric acid ELECTROLYTES AND NUTRIENTS
sodium ferric gluconate complexdrugId:1865 - PA ELECTROLYTES AND NUTRIENTS
sodium fluoride oral rinse ELECTROLYTES AND NUTRIENTS
sodium phenylacetate / sodium benzoate ELECTROLYTES AND NUTRIENTS
sucroferric oxyhydroxide ELECTROLYTES AND NUTRIENTS
SandostatindrugId:1269 # (octreotide)drugId:1269 ENDOCRINE/METABOLIC AGENTS
Sandostatin LAR (octreotide injectable suspension)drugId:2497 ENDOCRINE/METABOLIC AGENTS
Signifor (pasireotide)drugId:2791 - PA ENDOCRINE/METABOLIC AGENTS
Signifor LAR (pasireotide injectable suspension)drugId:4912 - PA ENDOCRINE/METABOLIC AGENTS
Somatuline (lanreotide)drugId:1020 ENDOCRINE/METABOLIC AGENTS
Santyl (collagenase) ENZYMES
sapropterindrugId:1831 - PA ENZYMES
sebelipase alfadrugId:5388 - PA ENZYMES
sodium phenylbutyrate powder ENZYMES
sodium phenylbutyrate tablet BP ENZYMES
Strensiq (asfotase alfa)drugId:5300 - PA ENZYMES
sertaconazoledrugId:1843 - PA FUNGICIDES
Sporanox (itraconazole solution)drugId:7060 BP FUNGICIDES
SporanoxdrugId:988 # (itraconazole 100 mg capsule)drugId:988 FUNGICIDES
sulconazoledrugId:1898 - PA FUNGICIDES
saccharomyces boulardiidrugId:6207 - PA ≥ 19 years GASTROINTESTINAL AGENT
sulfasalazinedrugId:1910 GI ANTI-INFLAMMATORY
sulfasalazine delayed-releasedrugId:4864 GI ANTI-INFLAMMATORY
Sernivo (betamethasone dipropionate spray)drugId:5396 - PA GLUCOCORTICOIDS
Solu-CortefdrugId:729 # (hydrocortisone injection-Solu-Cortef)drugId:729 GLUCOCORTICOIDS
Solu-MedroldrugId:964 # (methylprednisolone sodium succinate)drugId:964 GLUCOCORTICOIDS
Synalar (fluocinolone cream kit)drugId:5062 - PA GLUCOCORTICOIDS
Synalar (fluocinolone ointment kit)drugId:5063 - PA GLUCOCORTICOIDS
Synalar (fluocinolone solution kit)drugId:5064 - PA GLUCOCORTICOIDS
SynalardrugId:5060 # (fluocinolone 0.025% cream)drugId:5060 GLUCOCORTICOIDS
SynalardrugId:5061 # (fluocinolone ointment)drugId:5061 GLUCOCORTICOIDS
SynalardrugId:2632 # (fluocinolone solution)drugId:2632 GLUCOCORTICOIDS
sargramostimdrugId:1833 HEMATINIC AGENT
Siklos (hydroxyurea)drugId:6821 HEMATOLOGIC
Saizen (somatropin-Saizen)drugId:1886 - PA HORMONE AGENTS
Serostim (somatropin-Serostim)drugId:1887 - PA HORMONE AGENTS
somatropin-GenotropindrugId:1880 PD - PA HORMONE AGENTS
somatropin-HumatropedrugId:1881 - PA HORMONE AGENTS
somatropin-NorditropindrugId:1882 - PA HORMONE AGENTS
somatropin-Nutropin AQdrugId:1884 - PA HORMONE AGENTS
somatropin-OmnitropedrugId:1885 - PA HORMONE AGENTS
somatropin-SaizendrugId:1886 - PA HORMONE AGENTS
somatropin-SerostimdrugId:1887 - PA HORMONE AGENTS
somatropin-ZomactondrugId:5002 - PA HORMONE AGENTS
somatropin-ZorbtivedrugId:1889 - PA HORMONE AGENTS
Somavert (pegvisomant)drugId:1491 - PA HORMONE AGENTS
Stimate (desmopressin-Stimate) HORMONE AGENTS
Supprelin LA (histrelin-Supprelin LA)drugId:710 - PA HORMONE AGENTS
Synarel (nafarelin)drugId:1420 - PA HORMONE AGENTS
Striant (testosterone buccal system)drugId:2647 - PA HORMONE REPLACEMENT THERAPY
SandimmunedrugId:2092 # (cyclosporine)drugId:2092 IMMUNOMODULATOR
sarilumabdrugId:6181 - PA IMMUNOMODULATOR
secukinumabdrugId:4908 - PA IMMUNOMODULATOR
Siliq (brodalumab)drugId:6042 - PA IMMUNOMODULATOR
Simponi (golimumab)drugId:681 - PA IMMUNOMODULATOR
Simponi Aria (golimumab for infusion)drugId:2850 - PA IMMUNOMODULATOR
sirolimus solutiondrugId:7080 BP IMMUNOMODULATOR
sirolimus tabletdrugId:1857 IMMUNOMODULATOR
Skyrizi (risankizumab-rzaa)drugId:7227 - PA IMMUNOMODULATOR
Stelara (ustekinumab)drugId:1777 - PA IMMUNOMODULATOR
sennosidesdrugId:1842 * LAXATIVES
sodium phosphatedrugId:1873 LAXATIVES
sodium picosulfate / magnesium oxide / anhydrous citric acid-ClenpiqdrugId:6380 - PA LAXATIVES
sodium picosulfate / magnesium oxide / anhydrous citric acid-PrepopikdrugId:2644 LAXATIVES
sodium sulfate / potassium sulfate / magnesium sulfatedrugId:2086 - PA LAXATIVES
Suprep (sodium sulfate / potassium sulfate / magnesium sulfate)drugId:2086 - PA LAXATIVES
simvastatin 5 mg, 10 mg, 20 mg, 40 mgdrugId:2737 - PA > 45 units/month LIPID LOWERING AGENTS
simvastatin 80 mgdrugId:1855 - PA > 30 units/month LIPID LOWERING AGENTS
Skelaxin (metaxalone)drugId:1156 - PA MUSCLE RELAXANT
Soma (carisoprodol)drugId:180 - PA MUSCLE RELAXANT
Sinuva (mometasone sinus implant)drugId:6684 - PA NASAL PREPARATIONS
sodium chloride 3.5%, 7% for inhalation - Non-Drug Product NON-DRUG PRODUCT
sodium chloride 6% for inhalation - Non-Drug Product NON-DRUG PRODUCT
Supartz (hyaluronate-Supartz)drugId:4809 - PA; Non-Drug Product NON-DRUG PRODUCT
Synvisc (hylan G-F20-Synvisc)drugId:4810 - PA; Non-Drug Product NON-DRUG PRODUCT
Synvisc-One (hylan G-F20-Synvisc-One)drugId:4811 - PA; Non-Drug Product NON-DRUG PRODUCT
Sprix (ketorolac nasal spray)drugId:2289 - PA NONSTEROIDAL ANTI-INFLAMMATORY
Strattera # (atomoxetine) - PA < 6 years; See Table 31drugId:104; See Table 71drugId:3080 NONSTIMULANT ADHD AGENTS
Simbrinza (brinzolamide / brimonidine tartrate ophthalmic suspension)drugId:2849 - PA OPHTHALMIC PREPARATIONS
sulfacetamide / prednisolone sodium acetate ophthalmic ointment, suspensiondrugId:1877 - PA OPHTHALMIC PREPARATIONS
sulfacetamide / prednisolone sodium phosphate ophthalmic solutiondrugId:2272 OPHTHALMIC PREPARATIONS
sulfacetamide ophthalmic ointment, solutiondrugId:1901 OPHTHALMIC PREPARATIONS
Subsys (fentanyl sublingual spray)drugId:2523 - PA OPIOID ANALGESICS
Sufenta (sufentanil injection)drugId:2566 OPIOID ANALGESICS
sufentanil injectiondrugId:2566 OPIOID ANALGESICS
sufentanil powderdrugId:1897 - PA OPIOID ANALGESICS
Synalgos-DC (dihydrocodeine / aspirin / caffeine)drugId:525 - PA OPIOID ANALGESICS
Salagen # (pilocarpine) PARASYMPATHETIC AGENTS
suvorexant - PA; See Table 15drugId:4903; See Table 71drugId:4904 SEDATIVE, NON-BARBITURATE
Silenor (doxepin tablet-Silenor) - PA; See Table 15drugId:2082; See Table 71drugId:4346 SEDATIVES
sodium oxybatedrugId:1870 - PA SEDATIVES
Seromycin (cycloserine)drugId:2498 TB PREPARATIONS
Sirturo (bedaquiline)drugId:2851 - PA TB PREPARATIONS
Synthroid # (levothyroxine-Synthroid) THYROID PREPARATIONS
sumatriptan / naproxendrugId:1916 BP - PA TRIPTAN/NON STEROIDAL ANTI-INFLAMMATORY
sumatriptan injection-ImitrexdrugId:1914 - PA TRIPTAN
sumatriptan injection-SumaveldrugId:2245 - PA TRIPTAN
sumatriptan injection-ZembracedrugId:5599 - PA TRIPTAN
sumatriptan nasal powderdrugId:5590 - PA TRIPTAN
sumatriptan nasal spraydrugId:1913 - PA TRIPTAN
sumatriptan tabletdrugId:1915 - PA > 18 units/month TRIPTAN
Sumavel (sumatriptan injection-Sumavel)drugId:2245 - PA TRIPTAN
solifenacindrugId:1879 URINARY ANTISPASMODICS
Samsca (tolvaptan-Samsca)drugId:1728 - PA VASOPRESSIN ANTAGONISTS

MassHealth Drug List Footnotes
PA Prior authorization is required. The prescriber must obtain prior authorization for the drug in order for the pharmacy to receive payment. Note: Prior authorization applies to both the brand-name and the FDA "A"-rated generic equivalent of listed product.
# 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.
CO Carve-Out. This agent is listed on the Acute Hospital Carve-Out Drugs List and is subject to additional monitoring and billing requirements.
PD Preferred Drug. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class.
* The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization.
o Prior-authorization status depends on the drug's formulation.
^ This drug is available through the health care professional who administers the drug. MassHealth does not pay for this drug to be dispensed through a retail pharmacy.
1 Product may be available through the Massachusetts Department of Public Health (DPH). Please check with DPH for availability. MassHealth does not pay for immunizing biologicals (i.e., vaccines) and tubercular (TB) drugs that are available free of charge through local boards of public health or through the Massachusetts Department of Public Health without prior authorization (130 CMR 406.413(C)). In cases where free vaccines are available to providers for specific populations (e.g. children, high risk, etc.), MassHealth will reimburse the provider only for individuals not eligible for the free vaccines. Notwithstanding the above, MassHealth will pay pharmacies for seasonal flu vaccine serum without prior authorization, if the vaccine is administered in the pharmacy.
2 Prior authorization status is gender specific.

Note: Any drug that does not appear on the List requires prior authorization.

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Last updated 11/18/19