FDA-approved, for example:

• Corticosteroid-responsive dermatoses with secondary infection
• Plaque psoriasis
• Psoriasis vulgaris
• Scalp-related conditions (i.e., dermatoses, psoriasis, seborrheic dermatitis)
• Topical inflammatory and pruritic dermatoses

 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).

amcinonide cream and ointment, clobetasol foam/emollient, gel, and lotion, clocortolone cream, desoximetasone, diflorasone cream and ointment, fluocinolone kit, fluocinonide 0.1% cream, flurandrenolide cream, lotion, and ointment, fluticasone lotion, halcinonide cream, halobetasol foam, hydrocortisone butyrate lotion, hydrocortisone solution, triamcinolone 0.05% ointment and spray, brand-name topical corticosteroids (Apexicon-E, Bryhali, Cordran tape, Desonate, Halog ointment, Pandel, Sernivo, Ultravate lotion, Ultravate-X), and clobetasol foam and spray for non-scalp-related conditions

• Documentation of all of the following is required:
  • an appropriate diagnosis; and
  • an adverse reaction or inadequate response to all generic topical corticosteroids of the same potency and dosage form; or
   
  • medical necessity for a specific dosage form.

betamethasone foam, Capex, and clobetasol foam, shampoo, shampoo kit, and spray for scalp-related conditions

• Documentation of all of the following is required:
  • a scalp-related diagnosis; and
  • an adverse reaction or inadequate response to one generic topical corticosteroid of similar or greater potency and similar dosage form used on the scalp.

betamethasone/calcipotriene ointment and scalp suspension, Enstilar, and neomycin/fluocinolone cream and cream kit

• Documentation of all of the following is required:        
  • an appropriate diagnosis; and
  • compelling clinical rationale why the combination product would offer a therapeutic advantage over the commercially available separate agents. 

betamethasone dipropionate powder and clobetasol propionate powder

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

Duobrii (halobetasol/tazarotene lotion)

• Documentation of all of the following is required:        
  • diagnosis of plaque psoriasis; and
  • an adverse reaction or inadequate response to one superpotent or potent topical corticosteroid; and
  • compelling clinical rationale why the combination product would offer a therapeutic advantage over the commercially available separate agents.