FDA-approved, for example:

• Endogenous anterior uveitis (Durezol)
• Perennial (chronic) or seasonal (short term) allergic conjunctivitis (Alrex, Alocril, Alomide, Bepreve, Emadine, epinastine, Lastacaft, loteprednol 0.5% gel/ointment, olopatadine 0.1% and 0.2% eye drops, Pazeo)
• Postoperative pain and inflammation following ocular surgery (Acuvail, bromfenac 0.09%, Bromsite, Durezol, Ilevro, Inveltys, Lotemax SM, loteprednol 0.5% gel/ointment, Nevanac, Prolensa)
• Steroid-responsive inflammatory conditions (loteprednol 0.5% gel/ointment, Maxidex)
• Keratoconjunctivitis sicca (KCS)/dry eyes (Cequa, Lacrisert, Restasis Multidose, Xiidra)

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 requested medication (see below).  

Acuvail, bromfenac 0.09%, Bromsite and Prolensa

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • an inadequate response, adverse reaction, or contraindication to one of the following:
    • ketorolac 0.4% or 0.5%; or
    • diclofenac; or
    • flurbiprofen.

Alocril, Alomide, Bepreve, Brand-name Elestat, Emadine, Lastacaft, olopatadine 0.2% eye drops, Brand-name Patanol and Pazeo for members ≥ three years of age

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • an inadequate response, adverse reaction, or contraindication to a ketotifen product; and
  • an inadequate response, adverse reaction, or contraindication to azelastine ophthalmic solution; and
  • one of the following: 
    • an inadequate response or adverse reaction to epinastine; or
    • an inadequate response or adverse reaction to olopatadine eye drops; or
    • contraindication to epinastine and olopatadine eye drops; and
  • if the request is for Brand-name Elestat, Pataday, or Patanol, member must meet the above trials and provide medical records documenting an inadequate response or adverse reaction to the generic equivalent.

Alomide, Bepreve, Brand-name Elestat, Lastacaft, olopatadine 0.2% eye drops, and Pazeo for members ≥ two to < three years of age

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to epinastine; and
  • if the request is for Brand-name Elestat or Pataday, member must meet the above trials and provide medical records documenting an inadequate response or adverse reaction to the generic equivalent.

Alrex (for allergic conjunctivitis)

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • one of the following: 
    • an inadequate response or adverse reaction to ketotifen or azelastine ophthalmic solution; or
    • contraindication to ketotifen and azelastine ophthalmic solution.

Cequa

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • an inadequate response, adverse reaction, or contraindication to Restasis; and
  • member is ≥ 18 years of age; and
  • one of the following:
    • requested quantity is for ≤ 60 units/30 days; or
    • clinically appropriate rationale for dosing over the FDA approved regimen.

SmartPA: Claims for Cequa will usually process at the pharmacy for a quantity of ≤ 60 units/month if the member is  ≥ 18 years of age and there is a history of paid claims for 90 out of 120 days for Cequa or if there is a history of paid claims for Restasis in the most recent 90 days.^†

Durezol and Maxidex

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • an inadequate response, adverse reaction, or contraindication to a generic topical corticosteroid for ophthalmic use.

epinastine (generic) and olopatadine 0.1% eye drops (generic)

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • one of the following: 
    • the request is for epinastine and the member is ≥ two years of age; or
    • the request is for olopatadine 0.1% eye drops and the member is ≥ three years of age; and
  • for members ≥ three years of age, one of the following:
    • inadequate response or adverse reaction to azelastine ophthalmic solution; or
    • inadequate response or adverse reaction to ketotifen; or
    • contraindication to azelastine ophthalmic solution and ketotifen.

Ilevro and Nevanac

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • member is ≥ 10 years of age; and
  • an inadequate response, adverse reaction, or contraindication to one of the following:
    • ketorolac 0.4% or 0.5%; or
    • diclofenac; or
    • flurbiprofen.

Inveltys, Lotemax SM and loteprednol 0.5% gel/ointment (for postoperative pain and inflammation)

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • an inadequate response or adverse reaction to loteprednol 0.5% ophthalmic solution.

Lacrisert

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • an inadequate response, adverse reaction, or contraindication to two different artificial tear preparations. 

SmartPA: Claims for Lacrisert will usually process at the pharmacy if there is a history of paid claims for 2 different artificial tears formulations in the most recent 90 days or if there is a history of paid claims for the requested agent for 90 out of 120 days.^†

loteprednol 0.5% gel/ointment (for allergic conjunctivitis)

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • an inadequate response or adverse reaction to loteprednol 0.5% ophthalmic solution.

 Restasis Multidose

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • an inadequate response or adverse reaction to Restasis; and
  • member is ≥ 16 years of age; and
  • one of the following:
    • requested quantity is for ≤ 1 unit/28 days; or
    • clinically appropriate rationale for dosing over the FDA approved regimen.

Xiidra

• Documentation of the following is required: 
  • an appropriate diagnosis; and
  • an inadequate response, adverse reaction, or contraindication to Restasis; and 
  • member is ≥ 17 years of age; and
  • one of the following: 
    • requested quantity is for ≤ 60 units/30 days; or
    • clinically appropriate rationale for dosing over the FDA approved regimen.

SmartPA: Claims for Xiidra will usually process at the pharmacy for a quantity of ≤60 units/month if the member is  ≥ 17 years of age and there is a history of paid claims for 90 out of 120 days for Xiidra or if there is a history of paid claims for Restasis in the most recent 90 days.^†

^†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.