FDA-approved, for example:

• Alzheimer’s Disease
• Dementia associated with Parkinson’s Disease (rivastigmine)

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).

donepezil 23 mg tablet 

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • requested quantity does not exceed 30 tablets/month; and
  • an inadequate response to donepezil 20 mg/day for three consecutive months.

galantamine solution

• Documentation of all of the following is required: 
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • requested quantity does not exceed 180 mL/month; and
  • one of the following:
    • an inadequate response or adverse reaction to galantamine tablets or galantamine extended-release capsules; or
    • clinical rationale for solution formulation over solid oral formulation.

 memantine extended-release

• Documentation of all of the following is required: 
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • requested quantity does not exceed 30 capsules/month; and
  • an inadequate response or adverse reaction to memantine immediate-release tablets or solution

memantine solution

• Documentation of all of the following is required: 
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • requested quantity does not exceed 300 mL/month; and
  • one of the following:
    • an inadequate response or adverse reaction to memantine tablets or memantine extended-release capsules; or
    • clinical rationale for solution formulation over solid oral formulation.

Namzaric

• Documentation of all of the following is required: 
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • requested quantity does not exceed 30 capsules/month; and
  • one of the following:
    • member has been treated with stable doses of the separate agents for a minimum of three months; or
    • member has been stabilized for at least three months on Namzaric.

rivastigmine patch

• Documentation of all of the following is required: 
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • requested quantity does not exceed 30 units/month; and
  • one of the following:
    • an inadequate response or adverse reaction to rivastigmine capsules; or
    • clinical rationale for transdermal patch over solid oral formulation.

All agents at quantities requested above FDA approved limits

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • medical records documenting titration to doses exceeding FDA-recommendations.

All agents for members < 18 years of age

• Documentation of all of the following is required:
  • individual drug PA criteria must be met first where applicable; and
  • medical necessity for use in a pediatric member; and
  • prescriber is a psychiatrist or neurologist or a psychiatry or neurology consult is provided.