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Drug Category: Cardiovascular Agents

Medication Class/Individual Agents: Cardiovascular Agents

I. Prior-Authorization Requirements

 Cardiovascular Agents – Aldosterone Receptor Antagonists

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

eplerenone Inspra PA  

Carospir

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the use of a suspension formulation.

eplerenone for hypertension

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • adverse reaction, inadequate response or contraindication to all of the following:
      • thiazide diuretic; and
      • spironolactone; and
      • beta blocker; and
      • angiotensin converting enzyme (ACE inhibitor); and
      • angiotensin II receptor blocker (ARB); and
      • calcium channel blocker; and
    • requested dose is ≤ 2 tablets/day.

 

eplerenone for congestive heart failure (CHF) post-myocardial infarction

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • adverse reaction or inadequate response to spironolactone; and
    • requested dose is ≤ 2 tablets/day.

SmartPA: Claims for eplerenone at a quantity of ≤ 60 tablets/month will usually process at the pharmacy without a PA request if the member has a history of MassHealth medical claims for CHF and a history of paid MassHealth pharmacy claims for spironolactone or spironolactone/hydrochlorothiazide.†

 
spironolactone suspension Carospir PA  
spironolactone tablet Aldactone # test  

 Cardiovascular Agents – Alpha Agonists / Centrally Acting Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

clonidine patch Catapres-TTS BP PA  

clonidine patch

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • one of the following:
      • medical records documenting an inadequate response or adverse reaction to oral clonidine; or
      • clinical rationale for transdermal formulation; and
    • inadequate response or adverse reaction to two other antihypertensive agents.

 

clonidine powder

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

In addition to individual drug PA criteria where applicable, some behavioral health medications are subject to additional polypharmacy and age limit restrictions (see below).

 
clonidine powder PA  
clonidine tablet Catapres # PA   - < 3 years
guanfacine Tenex # PA   - < 3 years
methyldopa test  
reserpine test  

 Cardiovascular Agents – Alpha Blocking Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

doxazosin immediate-release Cardura # test  

phenoxybenzamine

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years old; and
    • appropriate dosing; and
    • one of the following:
      • inadequate response or adverse reaction to one selective α-1 blocker (prazosin, terazosin or doxazosin); or
      • contraindication to all selective α-1 blockers (prazosin, terazosin and doxazosin).
 
phenoxybenzamine Dibenzyline PA  
prazosin Minipress # test  
terazosin test  

 Cardiovascular Agents – Anti-Anginal Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

isosorbide dinitrate 40 mg tablet Isordil PA  

Gonitro, nitroglycerin lingual aerosol, nitroglycerin lingual spray

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • clinical rationale for use over nitroglycerin sublingual tablets.

Isordil 40mg

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • requested dose is > 40 mg per dose; and
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to two units of isosorbide dinitrate 20 mg tablet.

ranolazine

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • one of the following:
      • inadequate response or adverse reaction to two of the following: beta-blockers, nitrates, calcium channel blockers; or
      • contraindication to beta-blockers, nitrates, and calcium channel blockers.

SmartPA: Claims for ranolazine will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for 90 days in the past 120 days of the requested agent, or if the member has MassHealth medical claims for angina and a history of paid MassHealth pharmacy claims for two of the following classes: beta-blockers, nitrates, and calcium channel blockers.†

 
isosorbide dinitrate 5 mg, 10 mg, 20 mg, 30 mg tablet Isordil # test  
isosorbide dinitrate extended-release capsule Dilatrate-SR test  
isosorbide dinitrate extended-release tablet test  
isosorbide mononitrate test  
nitroglycerin 2% ointment Nitro-Bid # test  
nitroglycerin lingual aerosol Nitromist PA  
nitroglycerin lingual spray Nitrolingual PA  
nitroglycerin patch Nitro-Dur # test  
nitroglycerin sublingual powder Gonitro PA  
nitroglycerin sublingual tablet Nitrostat # test  
ranolazine Ranexa PA  

 Cardiovascular Agents – Beta-Adrenergic Blocking Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

acebutolol test  

 

Bystolic and Levatol

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • adverse reaction or an inadequate response to two different generic beta-blockers; and
    • adverse reaction or an inadequate response to one other antihypertensive agent.

 

carvedilol extended-release

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical necessity for carvedilol extended-release over carvedilol immediate-release.

 

Hemangeol

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the use of the solution dosage formulation.

 

Inderal XL, Innopran XL

  • Documentation of all of the following is required for patients with a diagnosis of hypertension:
    • diagnosis of hypertension; and
    • adverse reaction or inadequate response to a long-acting generic propranolol formulation; and
    • inadequate response or adverse reaction to two other antihypertensive agents, at least one of which is a generic beta-blocker.
  • Documentation of all of the following is required for patients with a diagnosis of migraine, angina, pulmonary hypertension, Raynaud’s syndrome:
    • diagnosis of migraine, angina, pulmonary hypertension, Raynaud’s syndrome; and
    • adverse reaction (not class specific) or inadequate response to a long-acting generic propranolol formulation.

 

Kapspargo (metoprolol extended-release capsule)

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • one of the following:
      • adverse reaction or inadequate response to metoprolol extended-release tablet; or
      • medical necessity for the use of a capsule formulation.

 

nadolol

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • adverse reaction or inadequate response to two generic beta-blockers that do not require PA.

SmartPA: Claims for nadolol will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for 90 days in the past 120 days of the requested agent, or if the member has MassHealth medical claims for hypertension, angina, arrhythmia, or migraine, and a history of paid MassHealth pharmacy claims for two generic beta-blockers that are covered without PA.†

 

Sotylize

  • Documentation of all of the following is required:
    • diagnosis of life-threatening ventricular arrhythmias or highly symptomatic atrial fibrillation or atrial flutter; and
    • clinical rationale why generic sotalol tablets may not be appropriate.
 
atenolol Tenormin # test  
betaxolol tablet test  
bisoprolol test  
carvedilol Coreg # test  
carvedilol extended-release Coreg CR PA  
esmolol Brevibloc # test  
labetalol test  
metoprolol Lopressor # test  
metoprolol extended-release capsule Kapspargo PA  
metoprolol extended-release tablet Toprol XL # test  
nadolol Corgard PA  
nebivolol Bystolic PA  
penbutolol Levatol PA  
pindolol test  
propranolol extended-release Inderal LA # test  
propranolol immediate-release test  
propranolol long-acting capsule Inderal XL PA  
propranolol long-acting capsule Innopran XL PA  
propranolol solution Hemangeol PA  
sotalol solution Sotylize PA  
sotalol tablet Betapace # test  
timolol tablet test  

 Cardiovascular Agents – Calcium Channel Blocking Agents - Dihydropyridine

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

amlodipine Norvasc # test  

nimodipine capsule and Nymalize > 21 days treatment/365 days

  • Documentation of all of the following is required:
    • appropriate diagnosis (subsequent episode of subarachnoid hemorrhage); and
    • dose and frequency are appropriate; and
    • if the request is for solution, medical necessity for the use of a solution formulation must be provided.

 

nisoldipine

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • one of the following:
      • adverse reaction or inadequate response to two generic calcium channel blockers (CCB) that do not require PA; or
      • clinical rationale why a CCB that does not require PA has not been tried.

SmartPA: Claims for nisoldipine will usually process at the pharmacy without a PA request if the member has MassHealth medical claims for an appropriate clinical indication (for example: hypertension, migraine, angina, pulmonary hypertension, or Raynaud’s phenomenon), and a history of paid MassHealth pharmacy claims for two generic non-PA CCB.†

 
clevidipine Cleviprex test  
felodipine extended-release test  
isradipine immediate-release test  
nicardipine test  
nifedipine capsule Procardia # test  
nifedipine extended-release Procardia XL # test  
nifedipine tablet Adalat # test  
nimodipine capsule PA   - > 21 days treatment/365 days
nimodipine oral solution Nymalize PA   - > 21 days treatment/365 days
nisoldipine Sular PA  

 Cardiovascular Agents – Calcium Channel Blocking Agents - Non-Dihydropyridine

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

diltiazem 120 mg, 180 mg, 240 mg, 300 mg-Cardizem CD Cardizem CD # test  

Cardizem CD (diltiazem) 360 mg

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • clinical rationale for the use of the 360 mg strength.
 
diltiazem 360 mg-Cardizem CD Cardizem CD PA  
diltiazem extended-release tablet Cardizem LA # test  
diltiazem-Cardizem Cardizem # test  
diltiazem-Tiazac ER Tiazac ER # test  
verapamil capsule Verelan # test  
verapamil extended-release Verelan PM # test  
verapamil sustained-release Calan SR # test  
verapamil tablet Calan # test  

 Cardiovascular Agents – Combination Antihypertensives

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

aliskiren / hydrochlorothiazide Tekturna HCT PA  

amlodipine/atorvastatin

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
      • one of the following:
        • inadequate response to ≥ 40 mg/day rosuvastatin for at least three months, adverse reaction or contraindication to rosuvastatin; or
        • clinical rationale for not using rosuvastatin; and
      • one of the following:
        • request is within quantity limits; or
        • medical necessity for the requested agent above quantity limits. 

SmartPA: Claims for amlodipine/atorvastatin at a quantity of 30 units/month will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for 90 days out of the last 120 days of the requested agent, or has a history of paid MassHealth pharmacy claims for rosuvastatin at a dose of at least 40 mg for at least three months in all claims history.

 

amlodipine/olmesartan, amlodipine/olmesartan/hydrochlorothiazide, amlodipine/telmisartan, amlodipine/valsartan/hydrochlorothiazide, Byvalson, candesartan/hydrochlorothiazide, captopril/hydrochlorothiazide, Edarbyclor, olmesartan/hydrochlorothiazide, Prestalia, Tekturna HCT, telmisartan/hydrochlorothiazide, trandolapril/verapamil

  • Documentation of one of the following is required:
    • stable dosing of each separate agent for at least three months; or
    • stability on the combination agent for at least three months; or
    • medical necessity for one agent in patients with complex, multiple, comorbid conditions.

SmartPA: Claims will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for 90 days (on separate agents or combination agents) in the past 120 days.†

 

Bidil

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

 

Concurrent therapy – ACE inhibitor, ARB, and/or direct renin inhibitor

  • Requests for concurrent therapy with two or more renin angiotensin system agents are evaluated on a case-by-case basis.

 

Entresto

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years old.
 
amiloride / hydrochlorothiazide test  
amlodipine / atorvastatin Caduet PA  
amlodipine / benazepril Lotrel # test  
amlodipine / olmesartan Azor PA  
amlodipine / olmesartan / hydrochlorothiazide Tribenzor PA  
amlodipine / telmisartan Twynsta PA  
amlodipine / valsartan Exforge # test  
amlodipine / valsartan / hydrochlorothiazide Exforge HCT PA  
atenolol / chlorthalidone Tenoretic # test  
azilsartan / chlorthalidone Edarbyclor PA  
benazepril / hydrochlorothiazide Lotensin HCT # test  
bisoprolol / hydrochlorothiazide Ziac # test  
candesartan / hydrochlorothiazide Atacand HCT PA  
captopril / hydrochlorothiazide PA  
clonidine / chlorthalidone test  
enalapril / hydrochlorothiazide Vaseretic # test  
fosinopril / hydrochlorothiazide test  
hydrochlorothiazide / triamterene Dyazide # test  
hydrochlorothiazide / triamterene Maxzide # test  
irbesartan / hydrochlorothiazide Avalide # test  
isosorbide dinitrate / hydralazine Bidil PA  
lisinopril / hydrochlorothiazide Zestoretic # test  
losartan / hydrochlorothiazide Hyzaar # test  
methyldopa / hydrochlorothiazide test  
metoprolol / hydrochlorothiazide Lopressor HCT # test  
moexipril / hydrochlorothiazide test  
nadolol / bendroflumethiazide Corzide # test  
nebivolol / valsartan Byvalson PA  
olmesartan / hydrochlorothiazide Benicar HCT PA  
perindopril / amlodipine Prestalia PA  
propranolol / hydrochlorothiazide test  
quinapril / hydrochlorothiazide Accuretic # test  
sacubitril / valsartan Entresto PA  
spironolactone / hydrochlorothiazide Aldactazide # test  
telmisartan / hydrochlorothiazide Micardis HCT PA  
trandolapril / verapamil Tarka PA  
valsartan / hydrochlorothiazide Diovan HCT # test  

 Cardiovascular Agents – Direct Vasodilators

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

hydralazine test  

    

 
minoxidil test  

 Cardiovascular Agents – Diuretics

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

amiloride test  

ethacrynic acid tablet

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • one of the following:
      • inadequate response or adverse reaction to furosemide, bumetanide or torsemide; or
      • contraindication to furosemide, bumetanide and torsemide.

SmartPA: Claims for ethacrynic acid tablet will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for furosemide, bumetanide or torsemide.†

triamterene

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • one of the following:
      • inadequate response or adverse reaction to spironolactone or amiloride; or
      • contraindication to spironolactone and amiloride.

SmartPA: Claims for triamterene will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for amiloride or spironolactone.†

 
bumetanide test  
chlorothiazide Diuril # test  
chlorthalidone test  
ethacrynic acid tablet Edecrin PA  
furosemide Lasix # test  
hydrochlorothiazide Microzide # test  
indapamide test  
methyclothiazide test  
metolazone test  
torsemide Demadex # test  
triamterene PA  

 Cardiovascular Agents – Ganglionic Blocking Agent

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

mecamylamine Vecamyl PA  

Vecamyl

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • prescriber is a cardiologist or nephrologist, or consult with a cardiologist or nephrologist is provided; and
    • causes of secondary hypertension have been ruled out or addressed; and
    • adverse reaction, inadequate response or contraindication to one agent from all of the following classes:
      • aldosterone antagonists; and
      • alpha agonists; and
      • angiotensin converting enzyme (ACE) inhibitors; and
      • angiotensin II receptor blockers (ARB); and
      • beta blockers; and
      • calcium channel blockers; and
      • diuretics (thiazide or loop).
 

 Cardiovascular Agents – HCN Channel Inhibitor

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

ivabradine Corlanor PA  

Corlanor

  • Documentation of all of the following is required:
    • an appropriate diagnosis; and
    • member is ≥ 18 years old; and
    • prescriber is a cardiologist, or consult with a cardiologist is provided; and
    • member has a resting heart rate of ≥ 70 beats per minute (bpm); and
    • one of the following:
      • member is currently receiving a beta-blocker (carvedilol, metoprolol succinate or bisoprolol) at maximally tolerated doses; or
      • adverse reaction to a beta-blocker; or
      • clinical rationale why a beta-blocker cannot be used; and
    • one of the following:
      • member had received standard of care therapy with an ACE inhibitor, ARB, or angiotensin-receptor neprilysin inhibitor (ARNI) in combination with a beta-blocker; or
      • clinical rationale why member cannot receive standard of care therapy with an ACE inhibitor, ARB, or ARNI in combination with a beta-blocker; and
    • request is within quantity limit of 60 units/30 days.
 

 Cardiovascular Agents – Not Otherwise Classified

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

droxidopa Northera PA  

Northera

  • Documentation of all of the following is required:
    • diagnosis of symptomatic neurogenic orthostatic hypotension (NOH) caused by one of the following:
      • primary autonomic failure; or
      • dopamine beta-hydroxylase deficiency; or
      • non-diabetic autonomic neuropathy (NDAN); and
    • inadequate response, adverse reaction, or contraindication to midodrine; and
    • inadequate response, adverse reaction, or contraindication to fludrocortisone.
 

 Cardiovascular Agents – Renin Angiotensin System Antagonists - Angiotensin II Receptor Antagonists (ARBS)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

azilsartan Edarbi PA  

candesartan, Edarbi, eprosartan, olmesartan, telmisartan

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to losartan; and
    • inadequate response, adverse reaction, or contraindication to irbesartan or valsartan.

SmartPA: Claims will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for 90 days in the past 120 days of the requested agent, or if the member has a history of paid MassHealth pharmacy claims for losartan and irbesartan or valsartan.†

 

Concurrent therapy – ACE inhibitor, ARB, and/or direct renin inhibitor

Requests for concurrent therapy with two or more renin angiotensin system agents are evaluated on a case-by-case basis.

 
candesartan Atacand PA  
eprosartan PA  
irbesartan Avapro # test  
losartan Cozaar # test  
olmesartan Benicar PA  
telmisartan Micardis PA  
valsartan Diovan # test  

 Cardiovascular Agents – Renin Angiotensin System Antagonists - Angiotensin-Converting Enzyme (ACE) Inhibitors

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

benazepril Lotensin # test  

captopril

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to two different generic ACE inhibitors.

SmartPA: Claims for captopril will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for 90 days in the past 120 days of the requested agent, or if the member has MassHealth medical claims for hypertension, heart failure, left ventricular dysfunction, myocardial infarction, or diabetic nephropathy and a history of paid MassHealth pharmacy claims for two generic ACE inhibitors that are covered without PA.†

 

Epaned and Qbrelis

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the use of a solution formulation.

 

Concurrent therapy – ACE inhibitor, ARB, and/or direct renin inhibitor

Requests for concurrent therapy with two or more renin angiotensin system agents are evaluated on a case-by-case basis.

 
captopril PA  
enalapril Vasotec # test  
enalapril solution Epaned PA  
fosinopril test  
lisinopril Prinivil # test  
lisinopril Zestril # test  
lisinopril solution Qbrelis PA  
moexipril test  
perindopril test  
quinapril Accupril # test  
ramipril Altace # test  
trandolapril test  

 Cardiovascular Agents – Renin Angiotensin System Antagonists - Direct Renin Inhibitors

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

aliskiren Tekturna BP PA  

aliskiren

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to an ACE inhibitor and an ARB.

 

Concurrent therapy – ACE inhibitor, ARB, and/or direct renin inhibitor

Requests for concurrent therapy with two or more renin angiotensin system agents are evaluated on a case-by-case basis.

 

 Cardiovascular Agents – Vasopressin Antagonist

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Clinical Notes

tolvaptan-Samsca Samsca PA  

Samsca

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years old; and
    • member is currently stabilized on the requested agent; and
    • one of the following:
      • request is within quantity limits of 30 units/30 days for 15 mg tablets or 60 units/30 days for 30 mg tablets; or
      • clinical rationale for high dose.
 
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
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:

  • Angina pectoris
  • Arrhythmias, paroxysmal supraventricular tachycardia
  • Cardiac arrhythmias
  • Cardiovascular events risk reduction
  • Congestive heart failure
  • Congestive heart failure post MI
  • Coronary artery disease (stable or variant angina)
  • Diabetic nephropathy
  • Euvolemic hyponatremia (SIADH)
  • Heart failure
  • Hypertension
  • Hypertrophic subaortic stenosis
  • Hypervolemic hyponatremia (CHF)
  • Left ventricular dysfunction
  • Left ventricular dysfunction following MI
  • Migraine prophylaxis
  • Myocardial infarction
  • Pheochromocytoma
  • Post-myocardial infarction
  • Proliferating infantile hemangioma
  • Raynaud phenomenon
  • Reduction of stroke risk with left ventricular hypertrophy
  • Subarachnoid hemorrhage (nimodipine)

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 requested medication (see below)

Please see clinical criteria for agents requiring PA in the table above under the Clinical Notes section.


In addition to individual drug PA criteria where applicable, some behavioral health medications are subject to additional polypharmacy and age limit restrictions.

  

Behavioral Health Medication Polypharmacy (pharmacy claims for any combination of four or more behavioral health medications [i.e., alpha2 agonists, antidepressants, antipsychotics, atomoxetine, benzodiazepines, buspirone, cerebral stimulants, hypnotic agents, and mood stabilizers] within a 45-day period) for members < 18 years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • For regimens including ≤ two mood stabilizers (also includes regimens that do not include a mood stabilizer), documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnoses; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided.

 

  • For regimens including ≥ three mood stabilizers, documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnoses; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; and
      • one of the following:
        • member has a seizure diagnosis only; or
        • member has an appropriate psychiatric diagnosis and one of the following:
          • cross-titration/taper of mood stabilizer therapy; or
          • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate; or
        • member has a diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain) and documentation that other clinically appropriate therapies have been tried and failed; therefore, multiple mood stabilizers are needed; or
        • member has psychiatric and comorbid diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain) and documentation that other clinically relevant therapies have been tried and failed; therefore, multiple mood stabilizers are needed, and one of the following:
          • cross-titration/taper of mood stabilizer therapy; or
          • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate.

SmartPA: Claims will usually process at the pharmacy without a PA request if the member is < 18 years of age, has a history of MassHealth medical claims for seizure, and has a history of paid MassHealth pharmacy claims for four or less behavioral health medications within the past 45 days and one mood stabilizer agent is identified as being used for seizure only.

 

 

Alpha Agonist for members < three years old

  • For all requests, individual drug PA criteria must be met first where applicable.  
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
      • member has a cardiovascular diagnosis only; or
    • all of the following:
      • appropriate diagnosis; and
      • treatment plan including names of current alpha agonist(s) and corresponding diagnoses; and
      • clinical rationale for use of alpha agonist in member < three years old.

  

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.


Original Effective Date: 04/2003

Last Revised Date: 08/2019


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Last updated 11/08/19