FDA-approved, for example:

• Bacterial vaginosis - Cleocin Vaginal Ovule, Clindesse, Nuvessa
• Treatment of impetigo or infection - mupirocin cream
• Eradication/prophylaxis of nasal colonization with methicillin-resistant Staphylococcusaureus (MRSA) in adult patients and health care workers to reduce the risk of infection during an institutional outbreak - Bactroban nasal ointment

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

• 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).

Bactroban nasal ointment for eradication/prophylaxis of nasal MRSA colonization in adult patients and health care workers to reduce the risk of infection during an institutional outbreak

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • request is for a quantity of ≤ 10 grams for 5 days.

Cleocin Vaginal Ovule, Clindesse, and Nuvessa

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • if the request is for Nuvessa, the member is ≥ 18 years of age; and
  • an inadequate response, adverse reaction, or contraindication to oral metronidazole tablets or metronidazole 0.75% gel; and
  • an inadequate response, adverse reaction, or contraindication to clindamycin 2% vaginal cream; and
  • appropriate dosing.

mupirocin cream for impetigo or infected traumatic lesions

Documentation of the following is required: 

• an appropriate diagnosis; and
• medical records documenting an inadequate response, adverse reaction, or contraindication to mupirocin ointment.

mupirocin powder

• Documentation of all the following is required:
  • appropriate diagnosis; and
  • clinical rationale why other commercially available alternatives cannot be used.