FDA-approved, for example:

• Ocular hypertension
• Open-angle glaucoma

Note: The above list may not include all FDA-approved indications.

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.
• 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 the member’s condition and requested medication (see below).

Azopt

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction or contraindication to dorzolamide 2%.

SmartPA: Claims for Azopt will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for dorzolamide 2%.†

bimatoprost 0.03% ophthalmic solution and Lumigan

• Documentation of the following is required:
  • appropriate diagnosis.

SmartPA: Claims for bimatoprost 0.03% ophthalmic solution and Lumigan will usually process at the pharmacy without a PA request if the member has a history of MassHealth medical claims for open angle glaucoma or ocular hypertension.†

dorzolamide/timolol preservative free and Xelpros

• Documentation of the following is required:
  • appropriate diagnosis; and
  • sensitivity to benzalkonium chloride or any other preservative used in ophthalmic preparations.

Rhopressa

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years old; and
  • one of the following:
    • inadequate response to combination therapy with a prostaglandin analog and an ophthalmic beta-blocker; or
    • contraindication or adverse reaction to prostaglandin analogs and ophthalmic beta-blockers; or
    • both of the following:
      • contraindication to ophthalmic beta-blockers; and
      • inadequate response or adverse reaction to a prostaglandin analog in combination with one of the following: ophthalmic alpha-2 adrenergic agonist, parasympathomimetic, carbonic anhydrase inhibitor; or
    • both of the following:
      • contraindication to prostaglandin analogs; and
      • inadequate response or adverse reaction to an ophthalmic beta-blocker in combination with one of the following: ophthalmic alpha-2 adrenergic agonist, parasympathomimetic, carbonic anhydrase inhibitor.

Simbrinza

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to any carbonic anhydrase inhibitor; and 
  • inadequate response or adverse reaction to any ophthalmic brimonidine product.  

SmartPA: Claims for Simbrinza will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for an ophthalmic brimonidine product and a carbonic anhydrase inhibitor.†

Timoptic Ocudose

• Documentation of the following is required:
  • appropriate diagnosis; and
  • one of the following:
    • inadequate response or adverse reaction to generically available ophthalmic timolol product that does not require a prior authorization; or 
    • sensitivity to benzalkonium chloride.

SmartPA: Claims for Timoptic Ocudose will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for a generic ophthalmic timolol product that does not require a prior authorization.†

timolol ophthalmic gel forming solution

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to an ophthalmic timolol-containing product.

SmartPA: Claims for timolol ophthalmic gel forming solution will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for an ophthalmic timolol-containing product.†

Vyzulta

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 17 years old; and
  • one of the following:
    • inadequate response to combination therapy with latanoprost solution and an ophthalmic beta-blocker; or
    • both of the following:
      • inadequate response to latanoprost solution; and
      • contraindication or adverse reaction to an ophthalmic beta-blocker.

Zioptan

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to Xelpros; and
  • one of the following:
    • inadequate response, adverse reaction or contraindication to latanoprost solution; or
    • sensitivity to benzalkonium chloride or any other preservative used in ophthalmic preparations.

SmartPA: Claims for Zioptan will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for latanoprost solution and Xelpros.†

† 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.