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Drug Category: Topical Agents

Medication Class/Individual Agents: Immune Suppressants

I. Prior-Authorization Requirements

 Dermatological Immune Suppressants

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

crisaborole Eucrisa PA  
pimecrolimus Elidel BP test  
tacrolimus topical Protopic BP test  

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.

 

Topical Immunosuppressants:

  • Crisaborole is a topical phosphodiesterase 4 inhibitor that is FDA-approved for the treatment of mild to moderate atopic dermatitis in patients two years of age and older.
 
Table Footnotes
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.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Atopic dermatitis (eczema)

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 the member’s condition and  requested medication (see below).

   

Eucrisa

  • Documentation of all of the following is required:
    • diagnosis of atopic dermatitis; and
    • member is ≥ two years of age; and
    • inadequate response, adverse reaction, or contraindication to one superpotent or potent topical corticosteroid; and
    • inadequate response, adverse reaction, or contraindication to one topical calcineurin inhibitor; and
    • one of the following:
      • request is for 60 grams/month; or
      • medical necessity for exceeding the quantity limits.

SmartPA: Claims for Eucrisa will usually process at the pharmacy without a PA request if the member is ≥ two years of age, has a history of MassHealth medical claims for atopic dermatitis, has a history of paid MassHealth pharmacy claims for one superpotent or potent topical corticosteroid, has a history of paid MassHealth pharmacy claims for one topical calcineurin inhibitor, and quantity is ≤ 60 grams/month.

  

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.

Please note: The MassHealth agency does not pay for any drug when used for cosmetic purposes as described in 130 CMR 406.413(B) “Limitations on Coverage of Drugs – Drug Exclusions” (see link below).

https://www.mass.gov/regulations/130-CMR-406000-pharmacy-services


Original Effective Date: 08/2005

Last Revised Date: 08/2019


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Last updated 11/25/19