FDA-approved, for example:

• Aspergillosis, blastomycosis, and histoplasmosis – Tolsura
• invasive Aspergillus infections – Cresemba, voriconazole suspension, tablet
• prevention of invasive Aspergillus and Candida infections – Noxafil injection, oral suspension, and DR tablet, voriconazole suspension, tablet
• candidemia and disseminated candidiasis  – voriconazole suspension, tablet
• esophageal candidiasis – voriconazole suspension, tablet
• fungal infections caused by Fusarium and Scedosporium – voriconazole suspension, tablet
• onychomycosis –  Onmel
• oropharyngeal candidiasis – Noxafil oral suspension, Oravig
• zygomycosis (mucormycosis) – Cresemba

Non FDA-approved, for example:

• Aspergillus endophthalmitis and keratitis – voriconazole suspension, tablet
• esophageal candidiasis – Noxafil oral suspension
• oropharyngeal candidiasis – voriconazole suspension, tablet
• zygomycosis (mucormycosis) – Noxafil injection, oral suspension, and DR tablet

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.
• Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

voriconazole suspension and tablet for the treatment of Exserohilum rostratum fungal infections due to contaminated compounded steroid injections (based on CDC recommendations)

• Documentation of the diagnosis is required for approval.  

Prevention of invasive aspergillus and candida fungal infections (Noxafil injection)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • clinical rationale for use of injectable formulation over oral formulations; and
  • member has a diagnosis of one of the following:
    • hematologic malignancy (e.g. acute myelogenous leukemia, myelodysplastic syndromes) with neutropenia; or
    • hematopoietic stem cell transplantation (HSCT); or
    • graft-versus-host disease (GVHD).

Prevention of invasive aspergillus and candida fungal infections (Noxafil oral suspension and Noxafil DR tablet)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 13 years of age; and
  • member has a diagnosis of one of the following:
    • hematologic malignancy (e.g. acute myelogenous leukemia, myelodysplastic syndromes) with neutropenia; or
    • hematopoietic stem cell transplantation (HSCT); or
    • graft-versus-host disease (GVHD).

Prevention of invasive aspergillus and candida fungal infections (voriconazole suspension, tablet)

• Documentation of the following is required:
  • member has a diagnosis of one of the following:
    • hematologic malignancy (e.g. acute myelogenous leukemia, myelodysplastic syndromes) with neutropenia; or
    • hematopoietic stem cell transplantation (HSCT); or
    • graft-versus-host disease (GVHD).

Treatment of aspergillosis, blastomycosis, and histoplasmosis (Tolsura)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical necessity for the 65 mg capsule instead of the 100 mg capsule.

Treatment of oropharyngeal candidiasis (Noxafil oral suspension)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 13 years of age; and
  • inadequate response, adverse reaction, or contraindication to all of the following:
    • oral fluconazole; and
    • itraconazole. 

Treatment of oropharyngeal candidiasis (Oravig)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to nystatin suspension; and
  • inadequate response, adverse reaction, or contraindication to clotrimazole troches.

Treatment of onychomycosis (Onmel)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical necessity for the 200 mg tablet instead of the 100 mg capsule.

Treatment of zygomycosis (mucormycosis) (Noxafil injection)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • clinical rationale for use of injectable formulation over oral formulations.

Treatment of zygomycosis (mucormycosis) (Noxafil oral suspension and Noxafil DR tablet)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 13 years of age.

SmartPA: Claims for Noxafil oral suspension and DR tablet will usually process at the pharmacy without a PA request for members who are ≥ 13 years of age with a history of MassHealth medical claims for zygomycosis (mucormycosis) within the last 365 days.^†

Treatment of zygomycosis (mucormycosis) (Cresemba)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • if the request is for the injectable formulation, prescriber provides clinical rationale for use over oral capsule.

SmartPA: Claims for Cresemba capsule will usually process at the pharmacy without a PA request for members who are ≥ 18 years of age with a history of MassHealth medical claims for zygomycosis (mucormycosis) within the last 365 days.^†

Treatment of esophageal candidiasis (Noxafil oral suspension)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 13 years of age; and
  • inadequate response, adverse reaction, or contraindication to all of the following:
    • oral fluconazole; and
    • itraconazole; and
    • voriconazole.

Treatment of aspergillus infections (Cresemba)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • inadequate response, adverse reaction, or contraindication to voriconazole; and
  • if the request is for the injectable formulation, prescriber provides clinical rationale for injectable formulation over oral capsule.

Treatment of aspergillus, scedosporium, and fusarium infections (voriconazole suspension, tablet)

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

SmartPA: Claims for voriconazole suspension or tablet will usually process at the pharmacy without a PA request for members with a history of MassHealth medical claims for aspergillus within the last 365 days.^†

Treatment of candidemia and disseminated candidiasis infections (voriconazole suspension, tablet)

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

Treatment of esophageal candidiasis (voriconazole suspension, tablet)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to all of the following:
    • oral fluconazole; and
    • itraconazole.

Treatment of oropharyngeal candidiasis (voriconazole suspension, tablet)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to one of the following:
    • nystatin suspension; or 
    • clotrimazole troches; or
    • miconazole troches; and
  • inadequate response, adverse reaction, or contraindication to oral fluconazole; and
  • inadequate response, adverse reaction, or contraindication to itraconazole; and
  • inadequate response, adverse reaction, or contraindication to posaconazole.

Treatment of aspergillus endophthalmitis and keratitis (voriconazole suspension, tablet)

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

^† 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.