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Table 71: Pediatric Behavioral Health


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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

Drug
Notes

clonidine patch Catapres-TTS PA   BP
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

Drug
Notes

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

Drug
Notes

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

Drug
Notes

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

Drug
Notes

esketamine Spravato PA  

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

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

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

Drug
Notes

bupropion hydrobromide extended-release Aplenzin PA   - < 6 years and PA > 30 units/month
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 PA   BP
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

Drug
Notes

citalopram Celexa PA   - < 6 years #
escitalopram Lexapro PA   - < 6 years #
fluoxetine 10 mg, 20 mg tablet for premenstrual dysphoric disorder Sarafem PA   - < 6 years #
fluoxetine 10 mg, 20 mg, 40 mg capsule, solution Prozac PA   - < 6 years #
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

Drug
Notes

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

Drug
Notes

desvenlafaxine extended-release PA  
desvenlafaxine extended-release-Khedezla Khedezla PA  
desvenlafaxine succinate extended-release Pristiq PA   - < 6 years and PA > 30 units/month #
duloxetine 20 mg, 30 mg, 60 mg capsule Cymbalta PA   - < 6 years #
duloxetine 40 mg capsule PA  
duloxetine sprinkle capsule Drizalma PA  
levomilnacipran Fetzima PA   - < 6 years and PA > 30 units/month
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

Drug
Notes

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

Drug
Notes

amphetamine extended-release 1.25 mg/mL oral suspension Adzenys ER PA  
amphetamine extended-release 2.5 mg/mL oral suspension Dyanavel XR PA  
amphetamine extended-release orally disintegrating tablet Adzenys XR-ODT PA  
amphetamine salts extended-release-Adderall XR Adderall XR PD PA   - < 3 years and PA > 60 units/month BP
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

Drug
Notes

dexmethylphenidate extended-release Focalin XR PD PA   - < 3 years and PA > 60 units/month BP
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-Adhansia XR Adhansia XR PA  
methylphenidate extended-release-Aptensio XR Aptensio XR PA  
methylphenidate extended-release-Concerta Concerta PA   - < 3 years and PA > 60 units/month BP
methylphenidate extended-release-Jornay PM Jornay PM PA  
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

Drug
Notes

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

Drug
Notes

amphetamine salts Adderall PA   - < 3 years and PA > 90 units/month #
amphetamine sulfate PA  
amphetamine sulfate orally disintegrating tablet Evekeo ODT 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

Drug
Notes

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

Drug
Notes

doxepin tablet-Silenor Silenor PA   BP
estazolam PA   - < 6 years and PA > 30 units/month
eszopiclone Lunesta PA   - < 6 years and PA > 1 unit/day #
flurazepam PA   - < 6 years and PA > 30 units/month
lemborexant Dayvigo PA  
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 > 1 unit/day
zolpidem 1.75 mg, 3.5 mg sublingual tablet Intermezzo PA  
zolpidem 10 mg tablet Ambien PA   - < 6 years and PA > 1 unit/day #
zolpidem 5 mg tablet Ambien PA   - < 6 years and PA > 1.5 units/day #
zolpidem 5 mg, 10 mg sublingual tablet Edluar PA  
zolpidem extended-release tablet Ambien CR PA   - < 6 years and PA > 1 unit/day #

 Pediatric Behavioral Health – Mood Stabilizers

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

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 #
cenobamate Xcopri PA  
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 powder PA  
lamotrigine tablet Lamictal PA   - < 6 years #
lamotrigine tablet starter kit Lamictal PA  
levetiracetam extended-release Keppra XR test   #
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 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 PA   BP
zonisamide test  

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

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

olanzapine / fluoxetine Symbyax PA  

 Pediatric Behavioral Health – Second-Generation (Atypical) Antipsychotics

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

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 PA  
aripiprazole solution PA   - < 6 years or ≥ 18 years and PA > 750 mL/month
aripiprazole tablet Abilify PA   - < 6 years and PA > 30 units/month #
aripiprazole tablet with sensor Abilify Mycite PA  
asenapine sublingual tablet Saphris PA  
asenapine transdermal Secuado 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  
lumateperone Caplyta 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 injections/month within the first 30 days of therapy and PA > 1 injection/month after 30 days of therapy
paliperidone extended-release 3-month injection Invega Trinza PD PA   - < 6 years and PA > 1 injection/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 injections/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 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.
  • 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 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 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 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

  • or 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, nasal and rectal diazepam, nasal midazolam, 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
      • 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
      • 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, Dayvigo, doxepin tablet, Edluar, temazepam 22.5 mg, and zolpidem 1.75 mg, 3.5 mg sublingual 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:
    • 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 

lithium

amoxapine

mirtazapine

cannabidiol3

methsuximide3

bupropion

nefazodone

carbamazepine

oxcarbazepine

citalopram

nortriptyline

cenobamate3

perampanel3

clomipramine

paroxetine

clobazam3

phenytoin3

desipramine

phenelzine

divalproex

pregabalin

desvenlafaxine

protriptyline

eslicarbazepine

primidone3

doxepin

selegiline2

ethosuximide3

rufinamide3

duloxetine

sertraline

ethotoin3

stiripentol3

escitalopram

tranylcypromine

felbamate3

tiagabine3

esketamine

trazodone

gabapentin

topiramate

fluoxetine

trimipramine

lacosamide3

valproic acid

fluvoxamine

venlafaxine

lamotrigine

vigabatrin3

imipramine

vilazodone

levetiracetam3

zonisamide3

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

suvorexant

brexpiprazole

paliperidone

estazolam

temazepam

cariprazine

perphenazine

eszopiclone

triazolam

chlorpromazine

perphenazine/amitriptyline

flurazepam

zaleplon

clozapine

pimozide

lemborexant

zolpidem

fluphenazine

quetiapine

Alpha2 Agonists

haloperidol

risperidone

clonidine

guanfacine

iloperidone

thioridazine

Miscellaneous

loxapine

thiothixene

atomoxetine

 

lumateperone

trifluoperazine

 

 

lurasidone

ziprasidone

 

 

molindone

 

 

 

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.

4Nasal and rectal diazepam and nasal midazolam formulations are excluded from the Pediatric Behavioral Health Medication Initiative requirements.

5Doxepin tablet 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: 08/2020


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Last updated 09/14/20

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