FDA-approved, for example:

• Ocular infections involving the conjunctiva and/or cornea
  • bacterial conjunctivitis
  • bacterial keratitis/corneal ulcers
  • blepharitis/blepharoconjunctivitis
  • surgical prophylaxis

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).

Single-entity agents: Azasite, Besivance, Ciloxan ointment, gatifloxacin, moxifloxacin ophthalmic solution, and Tobrex ointment 

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • an inadequate response, adverse reaction, or contraindication to one single-entity or combination ophthalmic antibiotic(s) agents not requiring prior authorization.

SmartPA: Claims for Besivance, gatifloxacin, and moxifloxacin ophthalmic solution will usually process and pay at the pharmacy without the requirements of a PA if the prescriber is an ophthalmologist.^†

Combination antibiotic/corticosteroid agents: Blephamide, Pred-G, Tobradex ointment, and Zylet

• Documentation of the following is required:
  • appropriate diagnosis; and
  • an inadequate response, adverse reaction, or contraindication to one of the following:
    • generic ophthalmic antibiotic/corticosteroid combination agent; or
    • generic single-entity or combination ophthalmic antibiotic(s) and single-entity ophthalmic corticosteroid agent.

Combination antibiotic/corticosteroid agent: Tobradex ST

• Documentation of the following is required:
  • an appropriate diagnosis; and
  • an inadequate response, adverse reaction, or contraindication to at least one generic combination ophthalmic antibiotic/corticosteroid agent or a single-entity or combination ophthalmic antibiotic(s) and single-entity ophthalmic corticosteroid agent; and
  • an inadequate response, adverse reaction, or contraindication to generic combination tobramycin 0.3%/dexamethasone 0.1% ophthalmic suspension.