FDA-approved, for example:

•  asthma
•  COPD
•  EIB

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 diagnosis and/or requested medication (see below).

 

Aerospan, Arnuity, and Qvar Redihaler

• Documentation of the following is required:      
  • diagnosis of asthma; and
  • one of the following:
    • inadequate response or adverse reaction to one inhaled corticosteroid that does not require a PA; or
    • contraindication to all inhaled corticosteroids that do not require a PA; and
  • one of the following:
    • If the request is for Aerospan or Qvar Redihaler, quantity limit of two inhalers per month; or
    • If request is for Arnuity, quantity limit of one inhaler per month.

SmartPA: Claims for Aerospan and Arnuity will usually process at the pharmacy without a PA request if within the quantity limit (Aerospan, quantity limit of two inhalers per month and Arnuity, quantity limit of one inhaler per month) and the member has a history of paid MassHealth pharmacy claims for at least 90 out of the last 120 days for the requested agent.^†

 

albuterol inhaler (generic Ventolin)

• Documentation of the following is required:
  • diagnosis of asthma, COPD, or EIB; and
  • an inadequate response, adverse reaction, or contraindication to albuterol inhaler (Proair, Proventil).

 

Anoro, Bevespi, Stiolto, and Utibron

• Documentation of the following is required: 
  • diagnosis of COPD; and
  • member is ≥ 18 years of age; and
  • quantity limit of one inhaler per month.

SmartPA: Claims for Anoro, Bevespi, Stiolto, and Utibron will usually process at the pharmacy within the quantity limit of one inhaler/month without a PA request if the member has a history of MassHealth medical claims for COPD and the member is ≥ 18 years of age.^†

  

Arcapta

• Documentation of the following is required:      
  • diagnosis of COPD; and
  • member is ≥ 18 years of age; and
  • quantity limit of 30 capsules per month.

SmartPA: Claims for Arcapta will usually process at the pharmacy within the quantity limit of 30 capsules/month without a PA request if the member has a history of MassHealth medical claims for COPD and the member is ≥ 18 years of age.^†

    

Armonair

• Documentation of the following is required:      
  • diagnosis of asthma; and
  • one of the following:
    • inadequate response or adverse reaction to Flovent; or
    • member is already receiving another Respiclick formulation; and
  • quantity limit of one inhaler per month.

 

Asmanex Twisthaler 110 mcg in members ≥ 12 years of age

• Documentation of the following is required:
  • diagnosis of asthma; and
  • clinical rationale for use of 110 mcg strength in members ≥ 12 years of age. 

SmartPA: Claims for Asmanex Twisthaler 110 mcg will usually process at the pharmacy if the member is < 12 years of age.^†

  

Asmanex Twisthaler 220 mcg in members < 12 years of age

• Documentation of the following is required:
  • diagnosis of asthma; and
  • clinical rationale for use of 220 mcg strength in members < 12 years of age. 

SmartPA: Claims for Asmanex Twisthaler 220 mcg will usually process at the pharmacy if the member is ≥ 12 years of age.^†

 

Breo

• Documentation of the following is required:      
  • diagnosis of COPD; or
  • diagnosis of asthma and one of the following:       
    • inadequate response to an inhaled or oral corticosteroid within the last four months; or
    • stable therapy within the last four months; or  
    • asthma that is classified as moderate-to-severe persistent; and
  • member is ≥ 18 years of age; and
  • quantity limit of one inhaler per month.

SmartPA: Claims for Breo will usually process at the pharmacy within the quantity limit of one inhaler/month without a PA request if the member (≥ 18 years of age) has a history of MassHealth medical claims for asthma and a history of paid MassHealth pharmacy claims for an inhaled or oral corticosteroid, Breo, Dulera, fluticasone/salmeterol inhalation aerosol, powder, or Symbicort within the past four months or, for the 100 mcg/25 mcg strength formulation only, if the member (≥ 18 years of age) has a history of MassHealth medical claims for COPD.^†

 

Brovana and Perforomist

•  Documentation of the following is required:      
  • diagnosis of COPD; and
  • member is ≥ 18 years of age; and
  • one of the following:      
    • member has a claim for a nebulized respiratory product and no claims for inhalers within the last month; or
    • clinical rationale for nebulized formulation; and
  • quantity limit of 120 mL per month.

SmartPA: Claims for Brovana and Perforomist will usually process at the pharmacy within the quantity limit of 120 mL/month without a PA request if the member (≥ 18 years of age) has a history of MassHealth medical claims for COPD, has a history of paid MassHealth pharmacy claims for a nebulized solution within the last month, and has no history of paid MassHealth pharmacy claims for an inhaler within the last month.^†

 

Dulera

• Documentation of the following is required:
  • diagnosis of asthma and one of the following: 
    • inadequate response to an inhaled or oral corticosteroid within the last four months; or
    • stable therapy within the last four months; or  
    • asthma that is classified as moderate-to-severe persistent; and
  • quantity limit of one inhaler per month.

  

fluticasone/salmeterol inhalation aerosol, powder (generic Advair) and Symbicort

• Documentation of the following is required:      
  • diagnosis of COPD; or
  • diagnosis of asthma and one of the following:       
    • inadequate response to an inhaled or oral corticosteroid within the last four months; or
    • stable therapy within the last four months; or  
    • asthma that is classified as moderate-to-severe persistent; and
  • quantity limit of one inhaler per month.

SmartPA: Claims for fluticasone/salmeterol inhalation aerosol, powder (generic Advair) and Symbicort will usually process at the pharmacy within the quantity limit of one inhaler/month without a PA request if the member has a history of MassHealth medical claims for COPD or if the member has a history of MassHealth medical claims for asthma and a history of paid MassHealth pharmacy claims for an inhaled or oral corticosteroid, Breo, Dulera, fluticasone/salmeterol inhalation aerosol, powder, or Symbicort within the past four months.^†

  

fluticasone/salmeterol inhalation powder (generic Airduo)

• Documentation of the following is required:
  • diagnosis of asthma and one of the following: 
    • inadequate response or adverse reaction to fluticasone/salmeterol inhalation aerosol, powder (generic Advair); or
    • clinical rationale for necessity of lower dose of fluticasone/salmeterol; or  
    • member is already receiving another Respiclick formulation; and
  • quantity limit of one inhaler per month.

 

Foradil and Serevent

• Documentation of the following is required:      
  • quantity limit of one inhaler per month; and
  • one of the following:      
    • diagnosis of COPD; or
    • all of the following:
      • diagnosis of asthma or EIB; and
      • inadequate response to monotherapy with an inhaled corticosteroid within the last four months; and
      • requested agent is going to be used concurrently with an inhaled corticosteroid.

SmartPA: Claims for Foradil and Serevent will usually process at the pharmacy within the quantity limit of one inhaler/month without a PA request if the member has a history of MassHealth medical claims for COPD.^†

    

Incruse > 1 inhaler/month, Seebri > 1 inhaler/month, Spiriva Handihaler > 30 units/month, and Tudorza > 1 inhaler/month

• Documentation of the following is required:
  • diagnosis of COPD; and
  • an inadequate response to the requested agent dosed at standard dosing; and
  • an inadequate response, adverse reaction, or contraindication to a long-acting beta agonist; and
  • an inadequate response, adverse reaction, or contraindication to an inhaled corticosteroid.

 

levalbuterol solution

• Documentation of the following is required:
  • diagnosis of asthma, COPD, or EIB; and
  • an inadequate response, adverse reaction, or contraindication to inhaled albuterol solution; and
  • one of the following:
    • age ≤ 12 years of age; or
    • clinical rationale for nebulized formulation. 

 

Lonhala and Yupelri

•  Documentation of the following is required:      
  • diagnosis of COPD; and
  • member is ≥ 18 years of age; and
  • one of the following:      
    • member has a claim for a nebulized respiratory product and no claims for inhalers within the last month; or
    • clinical rationale for nebulized formulation; and
  • an inadequate response, adverse reaction, or contraindication to ipratropium inhalation nebulizer solution; and
  • quantity limit of 60 mL per month for Lonhala or 90 mL per month for Yupelri.

SmartPA: Claims for Lonhala Magnair and Yupelri will usually process at the pharmacy within the quantity limit of 60 mL/month without a PA request if the member (≥ 18 years of age) has a history of MassHealth medical claims for COPD, has a history of paid MassHealth pharmacy claims for a nebulized solution within the last month, has no history of paid MassHealth pharmacy claims for an inhaler within the last month and has a history of paid MassHealth pharmacy claims for ipratropium inhalation nebulizer solution.^† 

 

Spiriva Respimat > 1 inhaler/month

• Documentation of the following is required:
  • for requests for the 2.5 mcg/actuation formulation, diagnosis of COPD; and 
  • for requests for the 1.25 mcg/actuation formulation, diagnosis of asthma; and
  • an inadequate response to the requested agent dosed at standard dosing; and
  • an inadequate response, adverse reaction, or contraindication to a long-acting beta agonist; and
  • an inadequate response, adverse reaction, or contraindication to an inhaled corticosteroid.

 

Striverdi

• Documentation of the following is required:   
  • diagnosis of COPD; and
  • member is ≥ 18 years of age; and
  • quantity limit of one inhaler per month.

SmartPA: Claims for Striverdi will usually process at the pharmacy within the quantity limit of one inhaler/month without a PA request if the member has a history of MassHealth medical claims for COPD and the member is ≥ 18 years of age.^†

  

Trelegy

• Documentation of the following is required:      
  • diagnosis of COPD; and
  • member is ≥ 18 years of age; and
  • one of the following:
    • inadequate response to ≥ three months of the separate agents Breo and Incruse once daily; or
    • adverse reaction to the separate agents Breo and Incruse once daily; or
    • clinical rationale why member cannot utilize the combination of the separate agents Breo and Incruse once daily; and
  • quantity limit of one inhaler per 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.