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Drug Category: Behavioral Health

Medication Class/Individual Agents: various

I. Prior-Authorization Requirements

 Pediatric Behavioral Health – Alpha Agonists

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

clonidine patch Catapres-TTS BP PA  
clonidine powder PA  
clonidine tablet Catapres # PA   - < 3 years
guanfacine Tenex # PA   - < 3 years

Please note: For a comprehensive list of all behavioral health medications included in the Pediatric Behavioral Health Medication Initiative, please see Appendix I below.  The member will need to meet all criteria for the requested agent as specified in the respective medication class guideline, if applicable.

 

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.

  • The American Academy of Child and Adolescent Psychiatry Practice Parameter on the use of Psychotropic Medications in Children and Adolescents encourages a complete medical and psychiatric evaluation before initiation of pharmacotherapy, a psychosocial and psychopharmacological treatment and monitoring strategy, and patient and family education about the treatment plan.1
  • A treatment and monitoring plan is essential to properly assess therapy response and adverse effects upon initiation, dose optimization, and discontinuation.  Appropriate follow-up allows for opportunities to educate the patient and family/caregiver and to address treatment plan concerns.1
  • Evidence-based and age appropriate psychosocial treatments should be tried prior to psychopharmacologic treatments in pediatric patients as clinically appropriate.2 Pharmacological treatments should be reserved for patients who have not responded to psychological treatment and if benefits outweigh the risks associated with treatment.3
  • Psychotherapy in combination with pharmacotherapy may lead to more favorable outcomes compared to either treatment alone.4,5 Patient and family/caregiver education about the importance of both interventions is essential.6
  • With initial treatment non-response, dose optimization or switching to an alternative agent should be considered prior to polypharmacy when clinically appropriate.7 Prescribers should have clear rationale for use of medication combinations to treat a condition, multiple comorbidities, and/or adverse effects resulting from therapy.1 At this time there is limited evidence supporting the use of medication polypharmacy from the same medication class, especially in the pediatric and adolescent population.1
  • Refractory patients and those considered as being a risk to self or others should be referred to a specialist provider.7

References:

1 American Academy of Child and Adolescent Psychiatry. Practice parameter on the use of psychotropic medications in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2006;48(9):961-73.

2 Gleason MM, Egger HL, Emslie GJ, Greenhill LL, Kowatch RA, Lieberman AF, et al. Psychopharmacological treatment for the very young: contexts and guidelines. J Am Acad Child Adolesc Psychiatry. 2007;46(12):1532-72.

3 Anderson IM, Ferrier IN, Baldwin RC, Cowen PJ, Howard L, Lewis G, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for the Psychopharmacology guidelines. J Psychopharmacology. 2008;22(4):343-96.

4 Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med 2008;359(26):2753-66.

5 March J, Silva S, Petrycki S, CurryJ, Wells K, Fairbank J, et al. Fluoxetine, cognitive-behavioral therapy and their combination for adolescents with depression: treatment for adolescents with depression (TADS) randomized controlled-trial. JAMA.2004;292(7):807-20.

6 Stroeh O and Trivedi H. Appropriate and judicious use of psychotropic medications in youth. Child Adolesc Psychiatric Clin N Am. 2012;21:703-11.

7 Balwin DS, Anderson IM, Nutt DJ, Allqulander C, Bandelow B, den Boer JA,  et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacology. 2014;28(5):403-39.

 

 Pediatric Behavioral Health – Antianxiety Agents - Benzodiazepines

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

alprazolam Xanax # PA   - < 6 years
alprazolam extended-release Xanax XR # PA   - < 6 years and PA > 60 units/month
alprazolam orally disintegrating tablet PA  
alprazolam powder PA  
chlordiazepoxide PA   - < 6 years
clonazepam 0.125 mg, 0.25 mg, 0.5 mg, 1 mg orally disintegrating tablet PA   - < 6 years and PA > 90 units/month
clonazepam 2 mg orally disintegrating tablet PA  
clonazepam powder PA  
clonazepam tablet Klonopin # PA   - < 6 years
clorazepate Tranxene # PA   - < 6 years
diazepam powder PA  
diazepam solution, tablet PA   - < 6 years
lorazepam powder PA  
lorazepam solution, tablet Ativan # PA   - < 6 years
midazolam powder PA  
midazolam syrup PA   - < 6 years
oxazepam PA   - < 6 years

 Pediatric Behavioral Health – Antianxiety Agents - Not Otherwise Classified

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

amitriptyline / chlordiazepoxide PA   - < 6 years
buspirone PA   - < 6 years
buspirone powder PA  
meprobamate PA  

 Pediatric Behavioral Health – Antidepressants - Monoamine Oxidase Inhibitors (MAOI)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

isocarboxazid Marplan PA  
phenelzine Nardil # PA   - < 6 years
selegiline transdermal patch Emsam PA  
tranylcypromine Parnate # PA   - < 6 years

 Pediatric Behavioral Health – Antidepressants - NMDA Receptor Antagonist

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

esketamine Spravato PA  

 Pediatric Behavioral Health – Antidepressants - Noradrenergic and Specific Serotonergic Antidepressants (NaSSA)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

mirtazapine Remeron # PA   - < 6 years
mirtazapine orally disintegrating tablet Remeron Sol Tab PA  

 Pediatric Behavioral Health – Antidepressants - Norepinephrine/Dopamine Reuptake Inhibitors (NDRI)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

bupropion hydrobromide extended-release Aplenzin PA  
bupropion hydrochloride Wellbutrin # PA   - < 6 years
bupropion hydrochloride extended-release 150 mg, 300 mg tablets Wellbutrin XL # PA   - < 6 years and PA > 30 units/month
bupropion hydrochloride extended-release 450 mg tablet Forfivo XL BP PA  
bupropion hydrochloride sustained-release-Wellbutrin SR Wellbutrin SR # PA   - < 6 years
bupropion hydrochloride sustained-release-Zyban Zyban # PA   - < 6 years

 Pediatric Behavioral Health – Antidepressants - Selective Serotonin Reuptake Inhibitors (SSRI)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

citalopram Celexa # PA   - < 6 years
escitalopram Lexapro # PA   - < 6 years
fluoxetine 10 mg tablet for premenstrual dysphoric disorder Sarafem # PA   - < 6 years
fluoxetine 10 mg, 20 mg, 40 mg capsule, solution Prozac # PA   - < 6 years
fluoxetine 20 mg tablet for premenstrual dysphoric disorder Sarafem PA  
fluoxetine 60 mg tablet PA  
fluoxetine 90 mg delayed-release capsule Prozac Weekly PA  
fluvoxamine extended-release PA  
fluvoxamine immediate-release PA   - < 6 years
paroxetine controlled-release Paxil CR PA  
paroxetine hydrochloride Paxil # PA   - < 6 years
paroxetine mesylate Pexeva PA  
sertraline Zoloft # PA   - < 6 years

 Pediatric Behavioral Health – Antidepressants - Serotonin Modulators

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

nefazodone PA   - < 6 years
trazodone 300 mg tablet PA  
trazodone 50 mg, 100 mg, 150 mg PA   - < 6 years
vilazodone Viibryd PA  
vortioxetine Trintellix PA  

 Pediatric Behavioral Health – Antidepressants - Serotonin/Norepinephrine Reuptake Inhibitors (SNRI)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

desvenlafaxine extended-release PA  
desvenlafaxine extended-release-Khedezla Khedezla PA  
desvenlafaxine succinate extended-release Pristiq PA  
duloxetine 20 mg, 30 mg, 60 mg Cymbalta # PA   - < 6 years
duloxetine 40 mg PA  
levomilnacipran Fetzima PA  
venlafaxine PA   - < 6 years
venlafaxine extended-release capsule Effexor XR # PA   - < 6 years
venlafaxine extended-release tablet PA  

 Pediatric Behavioral Health – Antidepressants - Tricyclic Antidepressants (TCA)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

amitriptyline powder PA  
amitriptyline tablet PA   - < 6 years
amoxapine PA   - < 6 years
clomipramine Anafranil PA  
desipramine Norpramin PA  
doxepin capsule, oral concentrate PA   - < 6 years
imipramine hydrochloride Tofranil # PA   - < 6 years
imipramine pamoate Tofranil-PM PA  
maprotiline PA   - < 6 years
nortriptyline Pamelor # PA   - < 6 years
protriptyline PA   - < 6 years
trimipramine Surmontil # PA   - < 6 years

 Pediatric Behavioral Health – Cerebral Stimulants and Miscellaneous Agents - Long-Acting Amphetamine Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

amphetamine extended-release oral suspension Adzenys ER PA  
amphetamine extended-release oral suspension Dyanavel XR PA  
amphetamine extended-release orally disintegrating tablet Adzenys XR-ODT PA  
amphetamine salts extended-release-Adderall XR Adderall XR BP PD PA   - < 3 years and PA > 60 units/month
amphetamine salts extended-release-Mydayis Mydayis PA  
lisdexamfetamine Vyvanse PD PA   - < 3 years and PA > 60 units/month

 Pediatric Behavioral Health – Cerebral Stimulants and Miscellaneous Agents - Long-Acting Methylphenidate Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

dexmethylphenidate extended-release Focalin XR BP PD PA   - < 3 years and PA > 60 units/month
methylphenidate extended-release 72 mg tablet PA  
methylphenidate extended-release chewable tablet Quillichew ER PA  
methylphenidate extended-release oral suspension Quillivant XR PA  
methylphenidate extended-release orally disintegrating tablet Cotempla XR-ODT PA  
methylphenidate extended-release-Aptensio XR Aptensio XR PA  
methylphenidate extended-release-Concerta Concerta BP PA   - < 3 years and PA > 60 units/month
methylphenidate extended-release-Metadate CD Metadate CD PA  
methylphenidate transdermal Daytrana PA  
methylphenidate-Ritalin LA Ritalin LA PA  

 Pediatric Behavioral Health – Cerebral Stimulants and Miscellaneous Agents - Not Otherwise Classified

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

atomoxetine Strattera # PA   - < 6 years
clonidine extended-release tablet PA  
guanfacine extended-release Intuniv # PA   - < 3 years

 Pediatric Behavioral Health – Cerebral Stimulants and Miscellaneous Agents - Short- and Intermediate-Acting Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

amphetamine salts Adderall # PA   - < 3 years and PA > 90 units/month
amphetamine sulfate PA  
dexmethylphenidate Focalin # PA   - < 3 years and PA > 90 units/month
dextroamphetamine 2.5 mg, 7.5 mg, 15 mg, 20 mg, 30 mg tablet PA  
dextroamphetamine 5 mg, 10 mg tablet PA   - < 3 years and PA > 90 units/month
dextroamphetamine 5 mg, 10 mg, 15 mg capsule Dexedrine # PA   - < 3 years and PA > 90 units/month
dextroamphetamine solution PA   - < 3 years and PA > 900 mL/month
methamphetamine Desoxyn PA  
methylphenidate chewable tablet PA   - < 3 years and PA > 90 units/month
methylphenidate oral solution Methylin oral solution # PA   - < 3 years and PA > 900 mL/month
methylphenidate powder PA  
methylphenidate sustained-release tablet PA   - < 3 years and PA > 90 units/month
methylphenidate-Ritalin Ritalin # PA   - < 3 years and PA > 90 units/month

 Pediatric Behavioral Health – First-Generation (Typical) Antipsychotics

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

amitriptyline / perphenazine PA   - < 6 years
chlorpromazine PA   - < 6 years
fluphenazine PA   - < 6 years
haloperidol Haldol # PA   - < 6 years
loxapine capsule Loxitane # PA   - < 6 years
molindone PA   - < 6 years
perphenazine PA   - < 6 years
pimozide Orap # PA   - < 6 years
thioridazine PA   - < 6 years
thiothixene Navane # PA   - < 6 years
trifluoperazine PA   - < 6 years

 Pediatric Behavioral Health – Hypnotics

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

doxepin tablet-Silenor Silenor PA  
estazolam PA   - < 6 years and PA > 30 units/month
eszopiclone Lunesta # PA   - < 6 years and PA > 30 units/month
flurazepam PA   - < 6 years and PA > 30 units/month
suvorexant Belsomra PA  
temazepam 22.5 mg Restoril PA  
temazepam 7.5 mg, 15 mg, 30 mg Restoril # PA   - < 6 years and PA >30 units/month
triazolam Halcion # PA   - < 6 years and PA > 30 units/month
zaleplon PA   - < 6 years and PA > 30 units/month
zolpidem 1.75 mg, 3.5 mg sublingual tablet Intermezzo PA  
zolpidem 10 mg tablet Ambien # PA   - < 6 years and PA > 30 units/month
zolpidem 5 mg tablet Ambien # PA   - < 6 years and PA > 45 units/month
zolpidem 5 mg, 10 mg sublingual tablet Edluar PA  
zolpidem extended-release tablet Ambien CR # PA   - < 6 years and PA > 30 units/month
zolpidem oral spray Zolpimist PA  

 Pediatric Behavioral Health – Mood Stabilizers

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

brivaracetam solution, tablet Briviact PA  
cannabidiol Epidiolex PA  
carbamazepine extended-release-Carbatrol Carbatrol # PA   - < 6 years
carbamazepine extended-release-Equetro Equetro PA  
carbamazepine extended-release-Tegretol XR Tegretol XR # PA   - < 6 years
carbamazepine-Tegretol Tegretol # PA   - < 6 years
clobazam film Sympazan PA  
clobazam suspension, tablet Onfi PA  
divalproex extended-release Depakote ER # PA   - < 6 years
divalproex immediate-release Depakote # PA   - < 6 years
divalproex sprinkle capsule Depakote # PA   - < 6 years
eslicarbazepine Aptiom PA  
ethosuximide Zarontin # test  
ethotoin Peganone test  
felbamate Felbatol # test  
gabapentin capsule, solution, tablet Neurontin # PA   - < 6 years
gabapentin powder PA  
lacosamide solution Vimpat PA  
lacosamide tablet Vimpat PA  
lamotrigine dispersible tablet Lamictal # PA   - < 6 years
lamotrigine extended-release tablet Lamictal XR PA  
lamotrigine extended-release tablet starter kit Lamictal XR PA  
lamotrigine orally disintegrating tablet Lamictal ODT PA  
lamotrigine orally disintegrating tablet starter kit Lamictal ODT PA  
lamotrigine tablet Lamictal # PA   - < 6 years
lamotrigine tablet starter kit Lamictal PA  
levetiracetam extended-release Keppra XR # PA   - < 6 years
levetiracetam injection, solution, tablet Keppra # test  
levetiracetam tablet for oral suspension Spritam PA  
lithium Lithobid # PA   - < 6 years
methsuximide Celontin test  
oxcarbazepine Trileptal # PA   - < 6 years
oxcarbazepine extended-release Oxtellar XR PA  
perampanel Fycompa PA  
phenytoin chewable tablet Dilantin Infatab # test  
phenytoin extended 200 mg and 300 mg capsule test  
phenytoin extended 30 mg and 100 mg capsule Dilantin # test  
phenytoin suspension Dilantin-125 # test  
pregabalin Lyrica BP PA  
pregabalin extended-release Lyrica CR PA  
primidone Mysoline # test  
rufinamide Banzel PA  
stiripentol Diacomit PA  
tiagabine Gabitril PA  
topiramate Topamax # PA   - < 6 years
topiramate extended-release capsule-Qudexy XR Qudexy XR PA  
topiramate extended-release capsule-Trokendi XR Trokendi XR PA  
topiramate powder PA  
topiramate sprinkle capsule Topamax # PA   - < 6 years
valproic acid Depakene # PA   - < 6 years
vigabatrin Sabril BP PA  
zonisamide test  

 Pediatric Behavioral Health – Second-Generation (Atypical) Antipsychotic-Selective Serotonin Reuptake Inhibitor

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

olanzapine / fluoxetine Symbyax PA  

 Pediatric Behavioral Health – Second-Generation (Atypical) Antipsychotics

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

aripiprazole extended-release injection Abilify Maintena PA  
aripiprazole lauroxil 1,064 mg Aristada PD PA   - < 6 years and PA > 1 injection/2 months
aripiprazole lauroxil 441 mg, 662 mg, 882 mg Aristada PD PA   - < 6 years and PA > 1 injection/month
aripiprazole lauroxil 675 mg Aristada Initio PD PA   - < 6 years and PA > 1 injection/month
aripiprazole orally disintegrating tablet Abilify Discmelt PA  
aripiprazole solution Abilify # PA   - < 6 years or ≥ 18 years and PA > 750 mL/month
aripiprazole tablet Abilify # PA   - < 6 years and PA > 30 units/month
asenapine Saphris PA  
brexpiprazole Rexulti PA  
cariprazine Vraylar PA  
clozapine orally disintegrating tablet Fazaclo PA  
clozapine suspension Versacloz PA  
clozapine tablet Clozaril # PA   - < 6 years
iloperidone Fanapt PA  
lurasidone Latuda PA  
olanzapine 15 mg orally disintegrating tablet Zyprexa Zydis # PA   - < 6 years and PA > 60 units/month
olanzapine 15 mg tablet Zyprexa # PA   - < 6 years and PA > 60 units/month
olanzapine 2.5 mg, 5 mg, 7.5 mg, 10 mg, 20 mg tablets Zyprexa # PA   - < 6 years and PA > 30 units/month
olanzapine 210 mg, 300 mg extended-release injection Zyprexa Relprevv PA   - < 6 years and PA > 2 injections/month
olanzapine 405 mg extended-release injection Zyprexa Relprevv PA   - < 6 years and PA > 1 injection/month
olanzapine 5 mg, 10 mg, 20 mg orally disintegrating tablet Zyprexa Zydis # PA   - < 6 years and PA > 30 units/month
paliperidone extended-release 1-month injection Invega Sustenna PA   - < 6 years, PA > 2 units/month within the first 30 days of therapy and PA > 1 unit/month after 30 days of therapy
paliperidone extended-release 3-month injection Invega Trinza PA   - < 6 years and PA > 1 unit/3 months
paliperidone tablet Invega PA  
quetiapine Seroquel # PA   - < 6 years and PA > 90 units/month
quetiapine extended-release 150 mg, 200 mg Seroquel XR # PA   - < 6 years and PA > 30 units/month
quetiapine extended-release 50 mg, 300 mg and 400 mg Seroquel XR # PA   - < 6 years and PA > 60 units/month
risperidone 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg tablets Risperdal # PA   - < 6 years and PA > 60 units/month
risperidone 0.25 mg, 4 mg orally disintegrating tablet Risperdal M-Tab PA  
risperidone 0.5 mg, 1 mg, 3 mg orally disintegrating tablet Risperdal M-Tab # PA   - < 6 years and PA > 60 units/month
risperidone 2 mg orally disintegrating tablet Risperdal M-Tab # PA   - < 6 years and PA > 240 units/month
risperidone 4 mg tablet Risperdal # PA   - < 6 years and PA > 120 units/month
risperidone extended-release intramuscular injection Risperdal Consta PA   - < 6 years and PA > 2 units (2 syringes)/month
risperidone extended-release subcutaneous injection Perseris PA  
risperidone solution Risperdal # PA   - < 6 years and PA > 480 mL/month
ziprasidone capsule Geodon # PA   - < 6 years and PA > 60 units/month
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 
PD Preferred Drug. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Anxiety
  • Attention Deficit Hyperactivity Disorder (ADHD)
  • Bipolar disorder
  • Depression
  • Hyperactivity associated with autism spectrum disorder
  • Psychotic disorders
  • Schizophrenia
  • Tourette's Disorder

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

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III.  Evaluation Criteria for Approval

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 diagnosis and/or requested medication (see below).

       

In addition to individual drug PA criteria where applicable, some behavioral health medications are subject to additional polypharmacy and age limit restrictions.

  

 **Please note: The member will need to meet all criteria for the requested agent as specified in the respective medication class table, if applicable.**

 

Behavioral Health Medication Polypharmacy (pharmacy claims for any combination of four or more behavioral health medications [i.e., alpha2 agonists, antidepressants, antipsychotics, atomoxetine, benzodiazepines, buspirone, cerebral stimulants, hypnotic agents, and mood stabilizers] within a 45-day period) for members < 18 years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • For regimens including ≤ two mood stabilizers (also includes regimens that do not include a mood stabilizer), documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnoses; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g.,  psychiatrist, neurologist) or consult is provided.

 

  • For regimens including ≥ three mood stabilizers, documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnoses; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; and
      • one of the following:
        • member has a seizure diagnosis only; or
        • member has an appropriate psychiatric diagnosis and one of the following:
          • cross-titration/taper of mood stabilizer therapy; or
          • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate; or
        • member has a diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain) and documentation that other clinically appropriate therapies have been tried and failed; therefore, multiple mood stabilizers are needed; or
        • member has psychiatric and comorbid diagnosis in which mood stabilizers may be clinically appropriate  (e.g., migraine, neuropathic pain) and documentation that other clinically relevant  therapies have been tried and failed; therefore, multiple mood stabilizers are needed, and one of the following:
          • cross-titration/taper of mood stabilizer therapy; or
          • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate.

SmartPA: Claims will usually process at the pharmacy without a PA request if the member is < 18 years of age, has a history of MassHealth medical claims for seizure, and has a history of paid MassHealth pharmacy claims for four or less behavioral health medications within the past 45 days and one mood stabilizer agent is identified as being used for seizure only.

 

Antidepressant Polypharmacy (overlapping pharmacy claims for two or more antidepressants for at least 60 days within a 90-day period) for members < 18 years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate psychiatric diagnosis; and
      • treatment plan including names of current antidepressants and corresponding diagnoses; and
      • prescriber is a psychiatrist or consult is provided; and
      • one of the following:
        • cross-titration/taper of antidepressant therapy; or
        • inadequate response (defined as four weeks of therapy) or adverse reaction to two monotherapy trials as clinically appropriate; or
        • antidepressant polypharmacy regimen of ≤ two antidepressants includes one of the following: bupropion, mirtazapine or trazodone; or
        • one antidepressant in the regimen is indicated for a comorbid condition in which antidepressants may be clinically appropriate.

SmartPA: Claims will usually process at the pharmacy without a PA request if the member is < 18 years of age and has a history of paid MassHealth pharmacy claims for two antidepressants for at least 60 days of therapy out of the last 90 days and one or both agents are trazodone, mirtazapine, or bupropion.

 

Antipsychotic Polypharmacy (overlapping pharmacy claims for two or more antipsychotics [includes first-generation and/or second-generation antipsychotics, except short-acting injectable formulations] for at least 60 days within a 90-day period) for members < 18 years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:

      • treatment plan including name, dose and frequency of all current behavioral health medications, associated target symptom(s), and behavioral health diagnoses; and
      • a comprehensive behavioral health plan (i.e. non-pharmacologic interventions) is in place; and
      • prescriber is a  psychiatrist or consult is provided; and
      • stage of treatment is acute, maintenance, or discontinuation; and
      • one of the following:
        • for acute stage (initiation of antipsychotic treatment likely with subsequent dose adjustments to maximize response and minimize side effects), one of the following:
          • cross-titration/taper of antipsychotic therapy; or
          • inadequate response or adverse reaction to two monotherapy trials as clinically appropriate; or
        • for maintenance stage (response to antipsychotic treatment with goal of remission or recovery), all of the following:
          • regimen is effective, therapy benefits outweigh risks, and appropriate monitoring is in place; and
          • if member has been on the antipsychotic regimen for the past 12 months, clinical rationale for extended therapy including at least one of the following: previous efforts to reduce/simplify the antipsychotic regimen in the past 24 months resulted in symptom exacerbation; or family/caregiver does not support the antipsychotic regimen change at this time due to risk of exacerbation; or other significant barrier for antipsychotic therapy discontinuation; or
        • for discontinuation stage (clinically indicated that the antipsychotic regimen can likely be successfully tapered), cross-titration/taper of antipsychotic therapy.

 

Benzodiazepine Polypharmacy (overlapping pharmacy claims for two or more benzodiazepines [hypnotic benzodiazepine agents, clobazam, rectal diazepam, and injectable formulations are not included] for at least 60 days within a 90-day period) for members < 18 years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • one of the following:
      • member  had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
      • member has a seizure diagnosis only; or
    • all of the following:
      • appropriate diagnosis; and
      • treatment plan including names of current benzodiazepines and corresponding diagnoses; and
      • one of the following:
        • cross-titration/taper of benzodiazepine therapy; or
        • clinical rationale for use of ≥ two benzodiazepines of different chemical entities.

 

Cerebral Stimulant Polypharmacy (overlapping pharmacy claims for two or more cerebral stimulants [immediate-release and extended-release formulations of the same chemical entity are counted as one] for at least 60 days within a 90-day period) for members < 18 years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnosis; and
      • treatment plan including names of current cerebral stimulants and corresponding diagnoses; and
      • inadequate response (defined as > seven days of therapy), adverse reaction, or contraindication to monotherapy trial with a methylphenidate product; and
      • inadequate response (defined as > seven days of therapy), adverse reaction, or contraindication to monotherapy trial with an amphetamine product; and
      • clinical rationale for cerebral stimulant polypharmacy.

 

Mood Stabilizer Polypharmacy (overlapping pharmacy claims for three or more mood stabilizers for at least 60 days within a 90-day period) for members < 18 years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required for members with seizure diagnosis only:
    • appropriate diagnosis (seizure) without comorbid condition.

 

  • Documentation of the following is required for members with psychiatric diagnoses:
    • one of the following:
      • member  had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
    • appropriate psychiatric diagnoses; and
    • treatment plan including names of current mood stabilizers and corresponding diagnoses; and
    • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; and
    • one of the following:
      • cross-titration/taper of mood stabilizer therapy; or
      • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate.

 

  • Documentation of the following is required for members with a diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain):
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain); and
      • treatment plan including names of current mood stabilizers and corresponding diagnoses; and
      • documentation that other clinically appropriate therapies have been tried and failed; therefore, multiple mood stabilizers are needed.

 

  • Documentation of the following is required for members with a psychiatric diagnosis and comorbid diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain):
    • one of the following:
      • member  had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • psychiatric diagnosis and diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain) ; and
      • treatment plan including names of current mood stabilizers and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; and
      • documentation that other clinically relevant therapies have been tried and failed; therefore, multiple mood stabilizers are needed; and
      • one of the following:
        • cross-titration/taper of mood stabilizer therapy; or
        • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate.

SmartPA: Claims will usually process at the pharmacy without a PA request if the member is < 18 years of age, has a history of MassHealth medical claims for seizure, and has a history of paid MassHealth pharmacy claims for three or less mood stabilizers for at least 60 days of therapy out of the last 90 days and one mood stabilizer agent is identified as being used for seizure only.

 

Antidepressant or buspirone for members < six years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnosis; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g. psychiatrist, neurologist) or consult is provided.

 

 Antipsychotic for members < six years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • complete medication treatment plan including name, dose and frequency of all current behavioral health medications, associated target symptom(s), and behavioral health diagnoses; and
      • a comprehensive behavioral health treatment plan (i.e., non-pharmacological interventions) is in place; and
      • prescriber is a specialist (e.g. child psychiatry, pediatric neurology, or developmental/behavioral pediatrics) or consult is provided; and
      • one of the following:
        • member is in acute stage of treatment (initiation of antipsychotic treatment likely with subsequent dose adjustments to maximize response and minimize side effects); or
        • all of the following:
          • member is in maintenance stage of treatment (response to antipsychotic treatment with goal of remission or recovery); and
          • regimen is effective, therapy benefits outweigh risks, and appropriate monitoring is in place; and
          • if member has been on the antipsychotic regimen for the past 12 months, clinical rationale for extended therapy including at least one of the following: previous efforts to reduce/simplify the antipsychotic regimen in the past 12 months resulted in symptom exacerbation; or family/caregiver does not support the antipsychotic regimen change at this time due to risk of exacerbation; or other significant barrier for antipsychotic therapy discontinuation; or
        • all of the following:
          • member is in discontinuation stage of treatment (clinically indicated that the antipsychotic regimen can likely be successfully tapered); and
          • cross-titration/taper of antipsychotic therapy.

 

Atomoxetine for members < six years old

  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnosis; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • if member is < three years old, prescriber is a specialist (e.g. psychiatrist) or consult is provided.

  

Benzodiazepine (hypnotic benzodiazepine agents are not included) or Mood Stabilizer (agents considered to be used only for seizure diagnoses are not included) for members < six years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
      • member has a seizure diagnosis only; or
    • all of the following:
      • appropriate diagnosis; and
      • treatment plan including names of current behavioral health medications and corresponding indications; and
      • prescriber is a specialist (e.g. psychiatrist, neurologist) or consult is provided.

SmartPA: Claims for mood stabilizers or benzodiazepines will usually process at the pharmacy without a PA request if the member is < six years of age, has a history of MassHealth medical claims for seizure, and does not have a history of MassHealth medical claims for psychiatric diagnoses and/or other diagnoses in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain).

 

Alpha2 Agonist for members < three years old

  • For all requests, individual drug PA criteria must be met first where applicable.  
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
      • member has a cardiovascular diagnosis only; or
    • all of the following:
      • appropriate diagnosis; and
      • treatment plan including names of current alpha2 agonist(s)  and corresponding diagnoses; and
      • clinical rationale for use of alpha2 agonist in member < three years old.

 

Cerebral Stimulant for members < three years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnosis; and
      • treatment plan including names of current cerebral stimulant(s) and corresponding diagnoses; and
      • clinical rationale for use of cerebral stimulant in member < three years old.

 

Estazolam, eszopiclone, flurazepam, temazepam 7.5 mg, 15 mg, and 30 mg, triazolam, zaleplon, zolpidem tablet, and zolpidem extended-release tablet for members < six years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required for members with a diagnosis of insomnia with other behavioral health comorbidities excluding ADHD:
    • treatment plan including name of current hypnotic agent and corresponding diagnosis; and
    • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided.

 

  • Documentation of the following is required for members with a diagnosis of insomnia without behavioral health comorbidities:
    • treatment plan including name of current hypnotic agent and corresponding diagnosis; and
    • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; and
    • inadequate response (defined by ≥ ten days of therapy), adverse reaction, or contraindication to melatonin.

 

  • Documentation of the following is required for members with a diagnosis of insomnia with comorbid ADHD:
    • treatment plan including name of current hypnotic agent and corresponding diagnosis; and
    • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; and
    • inadequate response (defined by ≥ ten days of therapy), adverse reaction, or contraindication to melatonin; and
    • inadequate response (defined by ≥ ten days of therapy), adverse reaction, or contraindication to clonidine.

 

Other hypnotic agents (Belsomra, Edluar, Silenor, temazepam 22.5 mg, zolpidem 1.75 mg, 3.5 mg sublingual tablet, and Zolpimist) for members < six years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • treatment plan including name of current hypnotic agent and corresponding diagnosis; and
    • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult was provided.

 

The following behavioral health medications are included in the Pediatric Behavioral Health Medication Initiative:

Appendix I:


Pediatric Behavioral Health Medication Initiative Medication List1

Antidepressants

Mood Stabilizers

amitriptyline

maprotiline

brivaracetam3 

methsuximide3

amoxapine

mirtazapine

cannabidiol3

oxcarbazepine

bupropion

nefazodone

carbamazepine

perampanel3

citalopram

nortriptyline

clobazam3

phenytoin3

clomipramine

paroxetine

divalproex

pregabalin

desipramine

phenelzine

eslicarbazepine

primidone3

desvenlafaxine

protriptyline

ethosuximide3

rufinamide3

doxepin

selegiline2

ethotoin3

stiripentol3

duloxetine

sertraline

felbamate3

tiagabine3

escitalopram

tranylcypromine

gabapentin

topiramate

esketamine

trazodone

lacosamide3

valproic acid

fluoxetine

trimipramine

lamotrigine

vigabatrin3

fluvoxamine

venlafaxine

levetiracetam3

zonisamide3

imipramine

vilazodone

lithium

 

isocarboxazid

vortioxetine

Antianxiety Agents

levomilnacipran

 

alprazolam

diazepam4

Stimulants

buspirone

lorazepam

amphetamine

lisdexamfetamine

chlordiazepoxide

meprobamate

dextroamphetamine

methamphetamine

chlordiazepoxide/

amitriptyline

midazolam

dexmethylphenidate

methylphenidate

clonazepam

oxazepam

dextroamphetamine/

amphetamine

 

clorazepate

 

Antipsychotics

 

 

aripiprazole

olanzapine

Hypnotics

asenapine

olanzapine/fluoxetine

doxepin5

temazepam

brexpiprazole

paliperidone

estazolam

triazolam

cariprazine

perphenazine

eszopiclone

zaleplon

chlorpromazine

perphenazine/amitriptyline

flurazepam

zolpidem

clozapine

pimozide

suvorexant

 

fluphenazine

quetiapine

Alpha2 Agonists

haloperidol

risperidone

clonidine

guanfacine

iloperidone

thioridazine

Miscellaneous

loxapine

thiothixene

atomoxetine

 

lurasidone

trifluoperazine

 

 

molindone

 ziprasidone

 

 

1Short-acting intramuscular injectable and intravenous formulations are excluded from the Pediatric Behavioral Health Medication Initiative requirements.

2Emsam (selegiline) is the only selegiline formulation included in the Pediatric Behavioral Health Medication Initiative.

3Agent is considered to be used only for seizure diagnoses and is excluded from age restriction for members less than six years of age.

4Rectal diazepam formulations are excluded from the Pediatric Behavioral Health Medication Initiative requirements.

5Silenor (doxepin) is classified as a hypnotic agent and the Pediatric Behavioral Health Medication Initiative requirements for antidepressants do not apply.  Pediatric Behavioral Health Medication Initiative requirements for hypnotics apply.

†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.


Original Effective Date: 11/2014

Last Revised Date: 07/2019


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Last updated 07/15/19