FDA-approved, for example:

• perennial or seasonal allergic rhinitis
• chronic idiopathic urticaria
• vasomotor (i.e., non-allergic) rhinitis

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

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

• All PA requests must include clinical diagnosis, drug name, dose, and frequency.
• A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
• For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
• Additional criteria may apply depending upon requested medication (see below).

azelastine 0.15% (generic Astepro) and olopatadine (generic Patanase) nasal sprays for allergic rhinitis

• Documentation of all of the following is required:  
  • an appropriate diagnosis; and
  • an inadequate response (defined by 14 days of therapy), adverse reaction, or contraindication to one intranasal corticosteroid agent; and
  • an inadequate response (defined by 14 days of therapy), adverse reaction, or contraindication to azelastine 137 mcg nasal spray; and
  • an inadequate response (defined by 14 days of therapy), adverse reaction, or contraindication to two second-generation selective antihistamines.
• For quantities greater than one inhaler/month, in addition to the above criteria, documentation must be provided regarding an inadequate clinical response at the manufacturer's recommended doses.

SmartPA: Claims for one inhaler/month of azelastine 0.15% nasal spray and olopatadine nasal spray will usually process at the pharmacy without a PA request if the member has MassHealth medical claims for allergic rhinitis and a history of paid pharmacy claims for ≥ 14 days out of the last 180 days of one intranasal corticosteroid, azelastine 137 mcg nasal spray and two second-generation selective antihistamines.

azelastine 0.15% (generic Astepro) and olopatadine (generic Patanase) nasal sprays for non-allergic rhinitis

• Documentation of all of the following is required:   
  • an appropriate diagnosis; and
  • an inadequate response (defined by 14 days of therapy), adverse reaction, or contraindication to one intranasal corticosteroid agent; and
  • an inadequate response (defined by 14 days of therapy), adverse reaction, or contraindication to azelastine 137 mcg nasal spray.
• For quantities greater than one inhaler/month, in addition to the above criteria, documentation must be provided regarding an inadequate clinical response at the manufacturer's recommended doses.

SmartPA: Claims for one inhaler/month of azelastine 0.15% nasal spray and olopatadine nasal spray will usually process at the pharmacy without a PA request if the member has MassHealth medical claims for non-allergic rhinitis and a history of paid pharmacy claims for ≥ 14 days out of the last 180 days of one intranasal corticosteroid and azelastine 137 mcg nasal spray.

carbinoxamine 6 mg tablet and Karbinal ER

• Documentation of all of the following is required:
  • an appropriate diagnosis; and
  • an inadequate response (defined by 14 days of therapy), adverse reaction, or contraindication to one intranasal corticosteroid agent; and 
  • an inadequate response (defined by 14 days of therapy), adverse reaction, or contraindication to two generic nonselective antihistamines; and
  • if request is for Karbinal ER, an inadequate response (defined by 14 days of therapy) or adverse reaction to immediate-release carbinoxamine solution; and
  • if request is for carbinoxamine 6 mg tablet, clinical rationale for use instead of carbinoxamine 4 mg tablet and immediate-release carbinoxamine solution.

Combination antihistamine/decongestant agents (i.e. Clarinex-D, Semprex-D)

• Documentation of all of the following is required:
  • an appropriate diagnosis; and
  • an inadequate response (defined by 14 days of therapy), adverse reaction, or contraindication to one intranasal corticosteroid (if the diagnosis is chronic idiopathic urticaria, a trial with an intranasal corticosteroid is not required); and
  • an inadequate response (defined by 14 days of therapy), adverse reaction, or contraindication to both loratadine/pseudoephedrine and cetirizine/pseudoephedrine.

SmartPA: Claims for a combination antihistamine/decongestant agent listed above will usually process at the pharmacy without a PA request if the member has MassHealth medical claims for allergic rhinitis or chronic idiopathic urticaria and a history of paid pharmacy claims for ≥ 14 days out of the last 180 days of loratadine/pseudoephedrine, cetirizine/pseudoephedrine, and an intranasal corticosteroid.

desloratadine ODT and levocetirizine solution

• Documentation of all of the following is required:
  • an appropriate diagnosis; and
  • a swallowing disorder or a condition affecting swallowing ability; and
  • an inadequate response (defined by 14 days of therapy), adverse reaction, or contraindication to one intranasal corticosteroid; and
  • an inadequate response (defined by 14 days of therapy) or adverse reaction to two of the following, or contraindication to all of the following: cetirizine, desloratadine, levocetirizine, and loratadine.

dexchlorpheniramine solution

• Documentation of all of the following is required:
  • an appropriate diagnosis; and
  • medical necessity for use of the requested agent over all other oral first- and second-generation antihistamines available in liquid formulation.

ketotifen powder

• Documentation of all of the following is required:
  • an appropriate diagnosis; and
  • clinical rationale why other commercially available alternatives cannot be used.

^†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.