FDA-approved, for example: 

• Relapsing-remitting MS
• Primary-progressive MS (Ocrevus)
• To improve walking in patients with MS (dalfampridine)

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

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

• All PA requests must include clinical diagnosis, drug name, dose, and frequency.
• A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
• Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

Aubagio, Gilenya, and Tecfidera

• Documentation of all of the following is required: 
  • diagnosis of relapsing-remitting MS; and
  • requesting prescriber is a neurologist or documents a consultation with a neurologist; and
  • requested quantity is ≤ 30 units/30 days (Aubagio and Gilenya) or ≤ 60 units/30 days (Tecfidera); and
  • for Gilenya, one of the following:
    • request is for the 0.5 mg strength and member weight is ≥ 40 kg; or
    • request is for the 0.25 mg strength and member weight is < 40 kg. 

dalfampridine

• Documentation of all of the following is required: 
  • diagnosis of improvement of walking in members with MS; and
  • member is ≥ 18 years of age; and
  • requesting prescriber is a neurologist or documents a consultation with a neurologist; and
  • requested quantity is ≤ 60 units/30 days.

Extavia

• Documentation of all of the following is required: 
  • diagnosis of relapsing-remitting MS; and
  • requesting prescriber is a neurologist or documents a consultation with a neurologist; and
  • medical necessity for use instead of Betaseron (interferon beta-1b).

Lemtrada

• Documentation of all of the following is required: 
  • diagnosis of relapsing-remitting MS; and
  • requesting prescriber is a neurologist or documents a consultation with a neurologist; and
  • requested dose is 12 mg daily for five days in first year of therapy or 12 mg daily for three days in second year of therapy; and
  • inadequate response or adverse reaction to two or contraindication to all of the following disease-modifying MS agents: Aubagio, Gilenya, glatiramer acetate therapy, interferon therapy, Ocrevus, Tecfidera, Tysabri, Zinbryta. 

Ocrevus

• Documentation of all of the following is required for a diagnosis of primary-progressive MS or relapsing-remitting MS: 
  • appropriate diagnosis; and
  • requesting prescriber is a neurologist or documents a consultation with a neurologist; and
  • requested dose is 600 mg every six months. 

Plegridy

• Documentation of all of the following is required: 
  • diagnosis of relapsing-remitting MS; and
  • requesting prescriber is a neurologist or documents a consultation with a neurologist; and
  • medical necessity for use instead of Avonex or Rebif (interferon beta-1a); and
  • requested dose does not exceed two units/28 days; and
  • one of the following:
    • inadequate response or adverse reaction to one of the following non-interferon disease-modifying MS agents: Aubagio, Gilenya, glatiramer acetate therapy, Lemtrada, Ocrevus, Tecfidera, Tysabri, Zinbryta; or
    • contraindication to the use of all other disease-modifying agents for the treatment of MS.

Zinbryta

• Documentation of all of the following is required: 
  • diagnosis of relapsing-remitting MS; and
  • requesting prescriber is a neurologist or documents a consultation with a neurologist; and
  • requested dosing does not exceed 150 mg monthly; and
  • one of the following:  
    • inadequate response or adverse reaction to two of the following disease-modifying MS agents: Aubagio, Gilenya, glatiramer, an interferon product (e.g. Avonex, Betaseron, Extavia, Plegridy, Rebif), Tecfidera; or
    • contraindication to the use of all other disease-modifying agents for the treatment of MS.