MassHealth Drug List
The MassHealth Drug List ("the List") is an alphabetical list of commonly prescribed drugs and therapeutic class tables. The List specifies which drugs need prior authorization (PA) when prescribed for MassHealth members. The PA requirements specified in the List reflect MassHealth's policy described in the pharmacy regulations and other communications from MassHealth, as well as MassHealth's and the Drug Utilization Review (DUR) Board's review of drugs within certain therapeutic classes. The List also specifies the generic over-the-counter drugs that are payable under MassHealth. Additional information can be found in the section titled "Prior-Authorization Status of Drugs."
The MassHealth Drug List (MHDL) Therapeutic Tables provide a view of drugs within their respective therapeutic classes, along with PA requirements, clinical information about the drug, and evaluation criteria for prior authorization for select therapeutic classes. The tables may not include all medications, dosage forms, and combination products within that therapeutic class. The criteria for prior authorization identify the clinical information MassHealth considers when determining medical necessity for selected medications. The criteria are based upon generally accepted standards of practice, review of the medical literature, federal and state policies, as well as laws applicable to the Massachusetts Medicaid Program. The clinical information included in the criteria is not intended to serve as a source of comprehensive prescribing information. Prescribers and pharmacists should review the List and its applicable therapeutic class tables when prescribing a drug or filling a prescription for a MassHealth member.
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. Any drug that does not appear on the List requires PA, except for drugs described in 130 CMR 406.413(B) (1) through (5) "Limitations on Coverage of Drugs - Drug Exclusions," which are not available to MassHealth adult members. Prescribers may request PA for such drugs for members under 21 years old to determine medical necessity (130 CMR 450.144(A)).
Updates to the List
The updates to the List are effective immediately, unless otherwise specified. For medications that have new PA requirements, MassHealth's policy permits an otherwise valid prescription written before the effective date to be filled for the life of the prescription without PA. Nevertheless, MassHealth encourages prescribers to reevaluate the medication regimens of their MassHealth patients, and consider either switching their MassHealth patients to a medication regimen that does not require PA or discontinuing the affected medication(s) as soon as possible, if clinically appropriate.
MassHealth encourages the use of specialized PA request forms for certain drugs or classes of drugs. These forms were created to help you provide the information MassHealth needs to evaluate your request. The specialized forms have the name of the drug or drug class in the title. If there is no specialized form, please use the standard Drug Prior Authorization Request form. All forms are available at www.mass.gov/druglist.
MassHealth evaluates the prior-authorization status of drugs on an ongoing basis, and updates the MHDLaccordingly. To sign up up for e-mail alerts that will notify you when the List has been updated, go to the MassHealth Drug List at www.mass.gov/druglist. Click on Introduction to the MassHealth Drug List and then click on Subscribe to E-Mail Alerts in the Introduction section of the MHDL. Send the e-mail that automatically appears on your screen, and you will be subscribed. To get a paper copy of an updated List, submit a written request to the following address, fax number, or e-mail.
P.O. Box 9152
Canton, MA 02021
Include your MassHealth provider number, address, and a contact name with your request. MassHealth Publications will send you the latest version of the List. You will need to submit another written request each time you want a paper copy.
Prior-Authorization Status of Drugs
Drugs may require PA for a variety of reasons. MassHealth determines the PA status of drugs on the List on the basis of the following:
- MassHealth program requirements; and
- ongoing evaluation of the drugs' utilization, therapeutic efficacy, safety, and cost.
Drugs are evaluated first on safety and effectiveness, and second on cost. Some drugs require prior authorization because MassHealth and the Drug Utilization Review Board have concluded that there are more cost-effective alternatives. With regard to all such drugs, MassHealth also has concluded that the more costly drugs have no significant clinically meaningful therapeutic advantage in terms of safety, therapeutic efficacy, or clinical outcome compared to those less-costly drugs used to treat the same condition.
Evaluation of a drug includes a thorough review by physicians and pharmacists using medical literature and consulting with specialists, other physicians, or both. References used may include AHFS Drug Information; Drug Facts and Comparisons, Micromedex; National Comprehensive Cancer Network (NCCN); literature from peer-reviewed medical journals; Drug Topics Red Book, Approved Drug Products with Therapeutic Equivalence Evaluations (also known as the "Orange Book"); the Massachusetts List of Interchangeable Drug Products, and manufacturers' product information.
In general, MassHealth strongly advocates the use of generic drugs. However, because of prevailing federal patent and rebate regulations, new-to-market generic drugs may cost more than the brand-name equivalent. For this reason, MassHealth may place a PA requirement on these generic drugs. This PA requirement typically lasts for six months, until the generic price drops.
The MassHealth Pharmacy Online Processing System (POPS) uses diagnosis codes from medical claims for some drug classes when processing claims at pharmacies. This means that a prescriber may not need to submit a paper PA form if a member's diagnosis in POPS meets the criteria for that drug. MassHealth uses technical software called Smart PA to link diagnosis codes from medical claims during pharmacy claims adjudication. Smart PA is used in the MHDL to identify drugs for which this process is currently available. For this reason, MassHealth requests pharmacies to submit all claims through POPS, as some drugs that are designated as requiring PA on the MHDL will process at the pharmacy without a paper PA submitted.
The List uses the following conventions.
- Brand-name products are capitalized. Generic products are in lowercase.
- Formulations of a drug (for example, salt forms, sustained release, or syrups) are not specified on the List, unless a particular formulation requires PA and a different formulation does not.
- Combination products are listed with the individual ingredients separated by a slash mark (/).
- Only the generic and brand names of over-the-counter drugs that are payable by MassHealth appear on the List. Those over-the-counter drugs that are not listed require PA.
- Only the generic names of single and combination vitamins are listed. The brand names of such combinations are not listed, and therefore require PA.
Questions or Comments
Pharmacists and prescribers who have questions or comments about the MassHealth Drug List may contact the Drug Utilization Review Program at 1-800-745-7318 or may e-mail the MassHealth Pharmacy Program at firstname.lastname@example.org. MassHealth does not answer all e-mail inquiries directly, but will use these inquiries to develop frequently asked questions about the MassHealth Drug List for its website.
When e-mailing a question or comment to the above e-mail address, please include your name, title, phone number, and fax number. This electronic mailbox should be used only for submitting questions or comments about the MassHealth Drug List. You will receive an automated response that acknowledges receipt of your e-mail. If you do not receive an automated reply, please resubmit your inquiry.
If a member has questions about the MassHealth Drug List, please refer the member to MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).
For more information about the MassHealth Pharmacy Program, including regulations, Pharmacy Facts, Publications and Notices sent to prescribers and pharmacies go to"www.mass.gov/masshealth/pharmacy"
Last Updated 08/19/15
This information is provided by MassHealth.