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									MassHealth Drug List
The MassHealth Drug List (“the List”) is an alphabetical list of commonly prescribed drugs and therapeutic class
tables. The List specifies which drugs need prior authorization (PA) when prescribed for MassHealth members.
The PA requirements specified in the List reflect MassHealth’s policy described in the pharmacy regulations and
other communications from MassHealth, as well as MassHealth’s and the Drug Utilization Review (DUR)
Board’s review of drugs within certain therapeutic classes. The List also specifies the generic over-the-counter
drugs that are payable under MassHealth. Additional information can be found in the section titled “Prior-
Authorization Status of Drugs.”

The MassHealth Drug List Therapeutic Tables provide a view of drugs within their respective therapeutic
classes, along with PA requirements, clinical information about the drug, and evaluation criteria for prior
authorization for select therapeutic classes. The tables may not include all medications, dosage forms, and
combination products within that therapeutic class. The criteria for prior authorization identify the clinical
information MassHealth considers when determining medical necessity for selected medications. The
criteria are based upon generally accepted standards of practice, review of the medical literature, federal
and state policies, as well as laws applicable to the Massachusetts Medicaid program. The clinical
information included in the criteria is not intended to serve as a source of comprehensive prescribing
information. Prescribers and pharmacists should review the List and its applicable therapeutic class
tables when prescribing a drug or filling a prescription for a MassHealth member.

MassHealth does not pay for immunizing biologicals (i.e., vaccines) and tubercular (TB) drugs that are available
free of charge through local boards of public health or through the Massachusetts Department of Public Health
without PA (130 CMR 406.413(C)). However, for the 2009-2010 flu season, MassHealth will pay pharmacies for
seasonal flu vaccine serum without prior authorization if the vaccine is not available free of charge. Any drug that
does not appear on the List requires PA, except for drugs described in 130 CMR 406.413(B) “Limitations on
Coverage of Drugs – Drug Exclusions,” which are not available to MassHealth adult members. Prescribers may
request PA for such drugs for members under 21 years old to determine medical necessity (130 CMR
450.144(A)).

Updates to the List
The updates to the List are effective immediately, unless otherwise specified. For medications that have
new PA requirements, MassHealth’s policy permits an otherwise valid prescription written before the
effective date to be filled for the life of the prescription without PA. Nevertheless, MassHealth
encourages prescribers to reevaluate the medication regimens of their MassHealth patients, and consider
either switching their MassHealth patients to a medication regimen that does not require PA or
discontinuing the affected medication(s) as soon as possible, if clinically appropriate.
MassHealth encourages the use of specialized PA request forms for certain drugs or classes of drugs.
These forms were created to help you provide the information MassHealth needs to evaluate your request.
The specialized forms have the name of the drug or drug class in the title. If there is no specialized form,
please use the standard Drug Prior Authorization Request form. All forms are available at
www.mass.gov/druglist.

Future Updates

MassHealth evaluates the prior-authorization status of drugs on an ongoing basis, and updates the
MassHealth Drug List accordingly. To sign up for e-mail alerts that will notify you when the List has
been updated, go to the MassHealth Drug List at www.mass.gov/druglist. Click on Introduction to the
May 3, 2010                                            i
MassHealth Drug List, then click on Subscribe to E-Mail Alerts in the Introduction section of the List.
Send the e-mail that automatically appears on your screen, and you will be subscribed. To get a paper
copy of an updated List, submit a written request to the following address, fax number, or e-mail.

        MassHealth Publications
        P.O. Box 9118
        Hingham, MA 02043
        Fax: 617-988-8973
        E-mail: publications@mahealth.net

Include your MassHealth provider number, address, and a contact name with your request. MassHealth
Publications will send you the latest version of the List. You will need to submit another written request
each time you want a paper copy.

1. Additions

    The following newly marketed drugs have been added to the MassHealth Drug List.

    Actemra (toclizumab) – PA
    Ampyra (dalfampridine) – PA
    Arzerra (ofatumumab) – PA
    Dysport (abobotulinumtoxin A) – PA
    Enemeez enema (docusate)
    Fluzone HD (influenza virus vaccine, high dose) – PA < 65 years
    Menveo–A/C/Y/W-135 (meningococcal quadrivalent vaccine)
    Nalfon 400 mg (fenoprofen) – PA
    Norvir (ritonavir) tablet – PA
    Oforta (fludaribine)
    Prevnar 13 (pneumococcal 13-valent conjugate vaccine)
    Urocit-K (potassium citrate) 15 meq – PA
    Victoza (liraglutide) – PA
    Votrient (pazopanib)
    Welchol (colesevelam) powder for suspension – PA
    Wilate (von Willebrand Factor/Coagulation Factor VIII Complex)
    Zyprexa Relprevv (olanzapine pamoate) 210 mg, 300 mg – PA > 2 injections/month
    Zyprexa Relprevv (olanzapine pamoate) 405 mg – PA > 1 injection/month

2. New FDA “A”-Rated Generic Drug

    The following FDA “A”-rated generic drugs have been added to the MassHealth Drug List. The
    brand name is listed with a # symbol to indicate that prior authorization is required for the brand.

        New FDA “A”-Rated Generic Drug                             Generic Equivalent of
        calcitonin, salmon                                         Miacalcin #
        ursodiol                                                   Urso #

3. Change in Prior-Authorization Status

    a. The PA requirements for Hepatitis antiviral agents are changing. The following PA requirements
       are effective May 17, 2010. Please see Table 44 and applicable PA request forms for PA
       requirements for the Hepatitis antiviral agents.

        Pegasys (peginterfereon alfa-2a) – PA
        PEG-Intron (peginterfereon alfa-2b) – PA



May 3, 2010                                           ii
    b. The following drug will require prior authorization effective May 17, 2010. Please see Table 13
       and applicable PA request forms for PA requirements for the lipid-lowering agents.

         Welchol (colesevelam) tablet – PA

    c. The following prior authorization requirements are effective May 17, 2010. Please see Table 40
       for the PA requirements for Leukotriene modifiers.

         Accolate (zafirlukast) – PA
         Singulair (montelukast) – PA

    d. The following will require prior authorization effective May 17, 2010.

         Cerezyme (imiglucerase) – PA
         Fosamax (alendronate) solution – PA
         Kristalose (lactulose) – PA
         Vancocin (vancomycin) capsule – PA
         Viread (tenofovir) – PA > 30 units/month

    e. The following agent was previously restricted to inpatient hospital use. MassHealth will now pay
       for this drug to be dispensed through the retail pharmacy or physician’s office.

         Folotyn (pralatrexate)

    f.   The following drugs no longer require prior authorization.

         Angeliq (drospirenone/estradiol)
         Femtrace (estradiol)

4. New and Revised Therapeutic Class and Clinical Criteria Tables

    Table 5 – Anti-TNF and Antipsoriatic Agents
    Table 10 – Dermatologic Agents – Acne and Rosacea
    Table 11 – Nonsteroidal Anti-Inflammatory Drugs
    Table 13 – Lipid-Lowering Agents
    Table 15 – Hypnotics
    Table 18 – Renin Angiotensin System Antagonists
    Table 20 – Anticonvulsants
    Table 22 – Calcium Channel Blocking Agents
    Table 24 – Atypical Antipsychotics
    Table 26 – Oral Antidiabetic Agents
    Table 30 – Botulinum Toxins (Types A and B)
    Table 32 – Serums, Toxoids, and Vaccines
    Table 35 – Antibiotics: Oral
    Table 38 – Antiretroviral/AIDS Therapy
    Table 40 – Leukotriene Modifiers
    Table 41 – Topical Antibacterials
    Table 43 – Pulmonary Arterial Hypertension Agents
    Table 44 – Hepatitis Antiviral Agents
    Table 45 – Injectable Antidiabetic Agents

Please note pricing information has been added to the following tables.
    Table 15 – Hypnotics
    Table 41 – Topical Antibacterials
    Table 43 – Pulmonary Arterial Hypertension Agents


May 3, 2010                                          iii
5. Updated Prior-Authorization Request Forms

       Antipsychotic Prior Authorization Request Form
       Hypnotic Prior Authorization Request Form
       Lipid-Lowering Agents Prior Authorization Request Form
       Oral Antibiotic Prior Authorization Request Form
       Proton Pump Inhibitor Prior Authorization Request Form

6. Updated MassHealth Drug List Pharmacy Initiative

   Pain Initiative

7. Updated MassHealth Drug List Quick Reference Guide

   The MassHealth Quick Reference Guide has been updated to reflect recent changes to the
   MassHealth Drug List.

8. Deletions

   a. The following MassHealth Evaluation Criteria has been discontinued.

       Table 43 – Hormone Replacement Agents

   b. The following drugs have been removed from the MassHealth Drug List because they have been
      discontinued by the manufacturer.

       Agenerase (amprenavir)
       Desyrel (trazodone)
       Ethmozine (morcizine)
       Foscavir (foscarnet)
       Humulin 50/50 (NPH insulin/regular insulin)
       Inversine (mecamylamine)
       Kapidex (dexlansoprazole)
       Kefurox (cefuroxime)
       Kemadrin (procyclidine)
       Lexxel (enalapril/felodipine)
       Pancrease (amylase/lipase/protease)
       Prosom (estazolam)
       Roferon A (interferon alfa 2a)
       Stelazine (trifluoperazine)
       Vesanoid (tretinoin)

   c. The following “A”-rated generic has been discontinued by the manufacturer. Prior authorization
      will no longer be required for the brand name formulation.
       ethinyl estradiol/norgestimate                         Ortho Tri-Cyclen Lo #
9. Name Change

   The manufacturer of the following drug is now marketing the product under a new trade name. The
   MassHealth Drug List has been updated to reflect this change.

   Previous Trade Name                                        New Trade Name

   Kapidex (deslansoprazole)                                  Dexilant (dexlansoprazole)



May 3, 2010                                       iv
10. Corrections

    a. The following drugs have been added to the MassHealth Drug List. They were omitted in error.
       These changes do not reflect any changes in MassHealth policy.

        Pancrease MT (amylase/lipase/protease)
        Urso Forte (ursodiol)

    b. The following drug has been added to the MassHealth OTC List. This was omitted in error. This
       change does not reflect any change in MassHealth policy.
        triple antibiotic ointment

Prior-Authorization Status of Drugs

Drugs may require PA for a variety of reasons. MassHealth determines the PA status of drugs on the List
on the basis of the following:

•   MassHealth program requirements; and
•   ongoing evaluation of the drugs’ utilization, therapeutic efficacy, safety, and cost.

Drugs are evaluated first on safety and effectiveness, and second on cost. Some drugs require prior
authorization because MassHealth and the Drug Utilization Review Board have concluded that there are
more cost-effective alternatives. With regard to all such drugs, MassHealth also has concluded that the
more costly drugs have no significant clinically meaningful therapeutic advantage in terms of safety,
therapeutic efficacy, or clinical outcome compared to those less-costly drugs used to treat the same
condition.

Evaluation of a drug includes a thorough review by physicians and pharmacists using medical literature and
consulting with specialists, other physicians, or both. References used may include AHFS Drug Information;
Drug Facts and Comparisons, Micromedex; literature from peer-reviewed medical journals; Drug Topics Red
Book, Approved Drug Products with Therapeutic Equivalence Evaluations (also known as the “Orange
Book”); the Massachusetts List of Interchangeable Drug Products; and manufacturers’ product information.

In general, MassHealth strongly advocates the use of generic drugs. However, because of prevailing
federal patent and rebate regulations, new-to-market generic drugs may cost more than the brand-name
equivalent. For this reason, MassHealth may place a PA requirement on these generic drugs. This PA
requirement typically lasts for six months, until the generic price drops.
The MassHealth Pharmacy Online Processing System (POPS) uses diagnosis codes from medical claims
for some drug classes when processing claims at pharmacies. This means that a prescriber may not need
to submit a paper PA form if a member’s diagnosis in POPS meets the criteria for that drug. MassHealth
uses technical software called Smart PA to link diagnosis codes from medical claims during pharmacy
claims adjudication. Smart PA is used in the MHDL to identify drugs for which this process is currently
available. For this reason, MassHealth requests pharmacies to submit all claims through POPS, as some
drugs that are designated as requiring PA on the MassHealth Drug List will process at the pharmacy
without a paper PA submitted.

List Conventions
The List uses the following conventions.
•   Brand-name products are capitalized. Generic products are in lowercase.
•   Formulations of a drug (for example, salt forms, sustained release, or syrups) are not specified on the
    List, unless a particular formulation requires PA.
•   Combination products are listed with the individual ingredients separated by a slash mark (/).
•   Only the generic and brand names of over-the-counter drugs that are payable by MassHealth appear

May 3, 2010                                            v
    on the List. Those brand-name over-the-counter drugs that are not listed require PA.
•   Only the generic names of antihistamine/decongestant combinations are listed. The brand names of
    such combinations are not listed, and therefore require PA.
•   Only the generic names of single and combination vitamins are listed. The brand names of
    such combinations are not listed, and therefore require PA.

Drug List on the MassHealth Web Site

The MassHealth Drug List can be found at www.mass.gov/druglist. It can also be accessed from our
home page at www.mass.gov/masshealth.

Questions or Comments
Pharmacists and prescribers who have questions or comments about the MassHealth Drug List may
contact the Drug Utilization Review Program at 1-800-745-7318 or may e-mail the MassHealth Pharmacy
Program at masshealthdruglist@state.ma.us. MassHealth does not answer all e-mail inquiries directly, but
will use these inquiries to develop frequently asked questions about the MassHealth Drug List for its Web
site.

When e-mailing a question or comment to the above e-mail address, please include your name, title, phone
number, and fax number. This electronic mailbox should be used only for submitting questions or comments
about the MassHealth Drug List. You will receive an automated response that acknowledges receipt of your e-
mail. If you do not receive an automated reply, please resubmit your inquiry.

If a member has questions about the MassHealth Drug List, please refer the member to MassHealth
Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss).


Therapeutic Class and Clinical Criteria Tables
Table No.      Table Name                                                                                                            Page

     1         Immune Globulins ....................................................................................................39
     2         Hormones – Gonadotropin-Releasing Hormone Analogs ........................................41
     3         Gastrointestinal Drugs – Histamine H2 Antagonists/Proton Pump Inhibitors ...........43
     4         Hematopoietic Agents...............................................................................................46
     5         Anti-TNF and Antipsoriatic Agents............................................................................48
     6         Smoking Cessation ...................................................................................................51
     7         Muscle Relaxants – Centrally Acting ........................................................................53
     8         Narcotic Agonist Analgesics .....................................................................................55
     9         Growth Hormones.....................................................................................................56
     10        Dermatologic Agents – Acne and Rosacea..............................................................58
     11        Nonsteroidal Anti-Inflammatory Drugs......................................................................61
     12        Antihistamines...........................................................................................................64
     13        Lipid-Lowering Agents ..............................................................................................66
     14        Triptans .....................................................................................................................69
     15        Hypnotics ..................................................................................................................72
     16        Topical Corticosteroids .............................................................................................74
     17        Antidepressants ........................................................................................................77
     18        Renin Angiotensin System Antagonists....................................................................81
     19        Alpha-1 Adrenergic Blockers ....................................................................................84
     20        Anticonvulsants.........................................................................................................86
     21        Beta-Adrenergic Blocking Agents .............................................................................91
     22        Calcium Channel Blocking Agents............................................................................93
     23        Respiratory Inhalant Products ..................................................................................95
     24        Atypical Antipsychotics. ............................................................................................97
     25        Intranasal Corticosteroids .........................................................................................99
     26        Oral Antidiabetic Agents .........................................................................................101
     27        5-HT3 Receptor Antagonists ...................................................................................103

May 3, 2010                                                            vi
       28              Dermatological Agents-Antifungal ..........................................................................105
       29              Allergy Agents: Ophthalmic ....................................................................................107
       30              Botulinum Toxins (Types A and B) .........................................................................109
       31              Cerebral Stimulants and Miscellaneous Agents .....................................................111
       32              Serums, Toxoids, and Vaccines .............................................................................114
       33              Selective Aldosterone Receptor Antagonists .........................................................116
       34              Antibiotics: Ophthalmic ...........................................................................................117
       35              Antibiotics: Oral .................................................................................................. 118
       36              Alcohol and Drug Cessation Agents ......................................................................120
       37              Palivizumab (Synagis) ...........................................................................................123
       38              Antiretroviral/AIDS Therapy ....................................................................................125
       39              Neuraminidase Inhibitors ........................................................................................127
       40              Leukotriene Modifiers..............................................................................................129
       41              Topical Antibacterials..............................................................................................131
       42              Dermatological Immune Suppressants...................................................................132
       43              Pulmonary Arterial Hypertension Agents................................................................133
       44              Hepatitis Antiviral Agents .......................................................................................135
       45              Injectable Antidiabetic Agents ................................................................................137
       46              Urinary Antispasmodics .........................................................................................139
       47              Oral Antifungal Agents ...........................................................................................141


Prior Authorization Request Forms
Anticonvulsant Prior Authorization Request ....................................................................................144
Antidepressant Prior Authorization Request ...................................................................................146
Antipsychotic Prior Authorization Request ......................................................................................148
Erythropoietin Prior Authorization Request ....................................................................................150
Forteo Prior Authorization Request ................................................................................................152
Growth Hormone Adult Prior Authorization Request ......................................................................154
Growth Hormone Pediatric Prior Authorization Request ................................................................156
Hypnotics Prior Authorization Request............................................................................................158
Immune Globulin Intravenous (IGIV) Prior Authorization Request .................................................160
Lipid-Lowering Agents Prior Authorization Request........................................................................162
Narcotic Prior Authorization Request ..............................................................................................164
Nonsteroidal Anti-Inflammatory Drugs (NSAID) Prior Authorization Request.................................166
Oral Anti-infectives Prior Authorization Request ............................................................................168
Proton Pump Inhibitor Prior Authorization Request.........................................................................170
Strattera and Cerebral Stimulant Prior Authorization Request........................................................172
Suboxone/Subutex .........................................................................................................................174
Triptan Prior Authorization Request ................................................................................................176
Trofile Assay and Selzentry (maraviroc) .........................................................................................178
Brand-Name Drug Prior Authorization Request (Use this form when requesting
    prior authorization for any other brand-name drug when there is an FDA
    “A”-rated generic available.)......................................................................................................180
Drug Prior Authorization Request (Use this form when requesting prior
    authorization for any drug.) .......................................................................................................182


Policy Initiative
Pain Initiative ...................................................................................................................................184


Other Information
MassHealth Drug List Quick Reference Guide ...............................................................................185
MassHealth Non-Drug Product List ...............................................................................................186
MassHealth Over-the-Counter (OTC) Drug List .............................................................................187
10 Tips for a Good Night’s Sleep.....................................................................................................188




May 3, 2010                                                                    vii
The List Uses the Following Symbols:
PA Prior authorization is required. The prescriber must obtain prior authorization for the drug in order for
   the pharmacy to receive payment.
# This is a brand-name drug with FDA “A”-rated generic equivalents. PA 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.
*   The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth
    without PA.

°   PA status depends on the drug’s formulation.
^   This drug is available through the health-care professional who administers the drug. MassHealth
    does not pay for this drug to be dispensed through a retail pharmacy.
H
    This drug is available only in an inpatient hospital setting. MassHealth does not pay for this drug to be
    dispensed through a retail pharmacy or a physician’s office.

Note: Any drug that does not appear on the List requires PA.




May 3, 2010                                           viii
Alphabetic List
A                                                     Actonel with Calcium (risedronate/calcium carbonate)
                                                        – PA
abacavir – see Table 38, p. 125
                                                      Actos (pioglitazone) – see Table 26, p. 101
abacavir/lamivudine – see Table 38, p. 125
                                                      ActoPlus Met (pioglitazone/metformin) – PA; see
abacavir/lamivudine/zidovudine – see Table 38,
                                                        Table 26, p. 101
  p. 125
                                                      Acular # (ketorolac)
abatacept – PA; see Table 5, p. 48
                                                      Acuvail (ketorolac ophthalmic solution) – PA
Abelcet (amphotericin B)
                                                      acyclovir °
Abilify (aripiprazole) tablet – PA > 30
                                                      Aczone (dapsone gel) – PA; see Table 10, p. 58
  units/month; see Table 24, p. 97
                                                      A&D, topical *
Abilify (aripiprazole) solution – PA > 750
                                                      Adacel (diphtheria/tetanus toxoids/acellular pertussis
  ml/month; see Table 24, p. 97
                                                        vaccine) – see Table 32, p. 114
Abilify Discmelt (aripiprazole, orally
                                                      Adalat # (nifedipine) – see Table 22, p. 93
  disintegrating tablet) – PA; see Table 24, p. 97
                                                      adalimumab – PA; see Table 5, p. 48
Abilify IM (aripiprazole injection) – see Table 24,
                                                      adapalene – PA; see Table 10, p. 58
  p. 97
                                                      adapalene/benzoyl peroxide – PA; see Table 10, p. 58
abobotulinumtoxin A – PA; see Table 30, p. 125
                                                      Adcirca (tadalafil) – PA; see Table 43, p. 133
Abraxane (paclitaxel)
                                                      Adderall # (amphetamine salts) – PA > 90
acamprosate – see Table 36, p. 120
                                                        units/month; see Table 31, p. 111
Acanya (clindamycin/benzoyl peroxide) – PA;
                                                      Adderall XR (amphetamine salts extended-release) –
  see Table 10, p. 58
                                                        PA; see Table 31, p. 111
acarbose – see Table 26, p. 101
                                                      adefovir – PA > 30 units/month; see Table 44, p. 135
Accolate (zafirlukast) – PA > 16 years; PA
                                                      Adoxa (doxycycline) – PA; see Table 10, p. 58; see
  (effective 05/17/10); see Table 40, p. 129
                                                        Table 35, p. 118
AccuNeb # (albuterol) – see Table 23, p. 95
                                                      Adrenalin (epinephrine)
Accupril # (quinapril) – see Table 18, p. 81
                                                      Adriamycin # (doxorubicin)
Accuretic # (quinapril/hydrochlorothiazide) – see
                                                      Adrucil # (fluorouracil)
  Table 18, p. 81
                                                      Advair diskus (fluticasone/salmeterol) – PA; see
Accutane # (isotretinoin) – PA > 21 years; see
                                                        Table 23, p. 95
  Table 10, p. 58
                                                      Advair HFA (fluticasone/salmeterol) – PA; see
acebutolol – see Table 21, p. 91
                                                        Table 23, p. 95
Aceon (perindopril) – PA; see Table 18, p. 81
                                                      Advate (antihemophilic factor, recombinant)
acetaminophen *
                                                      Advicor (lovastatin/niacin extended-release) – PA; see
Acetasol # (acetic acid)
                                                        Table 13, p. 66
Acetasol HC (acetic acid/hydrocortisone) – PA
                                                      Aerobid (flunisolide) – see Table 23, p. 95
acetazolamide
                                                      Aerobid-M (flunisolide) – see Table 23, p. 95
acetic acid
                                                      Afinitor 5 mg (everolimus) – PA > 30 units/month
acetic acid/hydrocortisone – PA
                                                      Afinitor 10 mg (everolimus)
acetohydroxamic acid
                                                      agalsidase – PA
acetylcysteine
                                                      Aggrenox (dipyridamole/aspirin)
Achromycin # (tetracycline)
                                                      Agrylin # (anagrelide)
Aciphex (rabeprazole) – PA; see Table 3, p. 43
                                                      A-Hydrocort # (hydrocortisone)
acitretin – see Table 10, p. 58
                                                      Ak-beta (levobunolol)
Aclovate (alclometasone) # – see Table 16,
                                                      Akineton (biperiden)
  p. 74
                                                      Akne-Mycin (erythromycin) – PA; see Table 10, p. 58
Acova (argatroban) – PA
                                                      Ak-Pentolate # (cyclopentolate)
acrivastine/pseudoephedrine – PA; see
                                                      Ak-Polybac # (bacitracin/polymyxin B)
  Table 12, p. 64
                                                      Ak-Spore HC # (neomycin/polymyxin B/
Actemra (toclizumab) – PA; see Table 5, p. 48
                                                        hydrocortisone)
Acthar (corticotropin) – PA
                                                      Ak-Sulf # (sulfacetamide)
ActHIB (haemophilus b conjugate vaccine) – see
                                                      Akten (lidocaine ophthalmic gel)
  Table 32, p. 114
                                                      Aktob # (tobramycin)
Acticin (permethrin)
                                                      Ak-tracin # (bacitracin)
Actigall # (ursodiol)
                                                      Ak-Trol # (neomycin/polymyxin
Actimmune (interferon gamma-1b)
                                                        B/dexamethasone)
Actiq (fentanyl transmucosal system) – PA; see
                                                      Alamast (pemirolast) – PA; see Table 29, p. 107
  Table 8, p. 55
                                                      Alaway (ketotifen) – see Table 29, p. 107
Activella # (estradiol/norethindrone)
                                                      albendazole
Actonel (risedronate) – PA
                                                      Albenza (albendazole)

May 3, 2010                                           1
Alphabetic List (cont.)

albumin                                               Alrex (loteprednol) – PA; see Table 29, p. 107
Albuminar-25 (albumin)                                Altabax (retapamulin) – PA; see Table 41, p. 131
albuterol                                             Altace # (ramipril), capsule – see Table 18, p. 81
albuterol, inhalation solution; see Table 23, p. 95   Altace (ramipril), tablet – PA; see Table 18, p. 81
albuterol °, inhaler – see Table 23, p. 95            Altoprev (lovastatin extended-release) – PA; see
albuterol/ipratropium, inhalation solution – see        Table 13, p. 66
   Table 23, p. 95                                    aluminum carbonate *
albuterol/ipratropium, inhaler – see Table 23,        aluminum hydroxide *
   p. 95                                              Alupent # (metaproterenol), inhalation solution – see
Alcet (oxycodone/acetaminophen) – PA; see               Table 23, p. 95
   Table 8, p. 55                                     Alupent (metaproterenol), inhaler – PA;
alclometasone – see Table 16, p. 74                     see Table 23, p. 95
Aldactazide #                                         Alvesco (ciclesonide) – see Table 23, p. 95
                                                                  H
   (spironolactone/hydrochlorothiazide)               alvimopan
Aldactone # (spironolactone)                          amantadine
Aldara (imiquimod) – PA                               Amaryl # (glimepiride) – see Table 26, p. 101
Aldoril-25 # (methyldopa/hydrochlorothiazide)         Ambien 5 mg # (zolpidem) – PA > 45 units/month;
Aldurazyme (laronidase) – PA                            see Table 15, p. 72
alefacept – PA; see Table 5, p. 48                    Ambien 10 mg # (zolpidem) – PA > 30 units/month;
alemtuzumab                                             see Table 15, p. 72
alendronate solution – PA (effective 5/17/10)         Ambien CR (zolpidem, extended-release tablet) – PA;
alendronate tablet                                      see Table 15, p. 72
alendronate/vitamin D3 – PA                           Ambisome (amphotericin B)
Alesse # (ethinyl estradiol/levonorgestrel)           ambrisentan – see Table 43, p. 133
Alferon N (interferon alfa-n3, human leukocyte        amcinonide – see Table 16, p. 74
   derived)                                           Amerge (naratriptan) – PA; see Table 14, p. 69
alfuzosin – PA; see Table 19, p. 84                   Americaine # (benzocaine)
alglucosidase – PA                                    A-Methapred # (methylprednisolone)
Alimta (pemetrexed)                                   Amevive (alefacept) – PA; see Table 5, p. 48
Alinia suspension (nitazoxanide) – PA                 Amicar # (aminocaproic acid)
Alinia tablet (nitazoxanide) – PA                     amikacin
aliskiren – PA; see Table 18, p. 81                   amiloride
aliskiren/ hydrochlorothiazide – PA; see              amiloride/hydrochlorothiazide
   Table 18, p. 81                                    Amino Acid Cervical (urea/sodium
aliskiren/ valsartan – PA; see Table 18, p. 81          proprionate/methionine/cystine/inositol)
alitretinoin – PA; see Table 10, p. 58                amino acid and electrolyte IV infusion
Alkeran (melphalan)                                   aminocaproic acid
Allegra (fexofenadine) – PA; see Table 12, p. 64      Amino-Cerv pH 5.5 (urea/sodium
Allegra-D (fexofenadine/pseudoephedrine) –              proprionate/methionine/cystine/inositol)
   PA; see Table 12, p. 64                            aminoglutethimide
Allegra ODT (fexofenadine orally disintegrating       aminophylline
   tablet) – PA; see Table 12, p. 64                  amiodarone
allopurinol                                           Amitiza (lubiprostone) – PA
almotriptan – PA; see Table 14, p. 69                 amitriptyline – see Table 17, p. 77
Alocril (nedocromil) – PA; see Table 29, p. 107       amitriptyline/chlordiazepoxide
Alomide (lodoxamide) – PA; see Table 29,              amitriptyline/perphenazine
   p. 107                                             amlodipine – see Table 22, p. 93
Alora (estradiol)                                     amlodipine/atorvastatin – PA; see Table 13, p. 66; see
alosetron – PA                                          Table 22, p. 93
Aloxi (palonosetron) – see Table 27, p. 103           amlodipine/benazepril – PA; see Table 18, p. 81; see
Alphagan P (brimonidine) °                              Table 22, p. 93
Alphanate (antihemophilic factor, human)              amlodipine/olmesartan – PA; see Table 18, p. 81; see
AlphaNine SD (factor IX, human)                         Table 22, p. 93
alpha1–proteinase inhibitor–human                     amlodipine/telmisartan – PA; see Table 18, p. 81; see
alprazolam                                              Table 22, p. 93
alprazolam extended-release – PA                      amlodipine/valsartan – PA; see Table 18, p. 81; see
alprazolam, orally disintegrating tablet – PA           Table 22, p. 93
alprazolam powder – PA                                amlodipine/valsartan/hydrochlorothiazide – PA; see
                                                        Table 18, p. 81

May 3, 2010                                           2
Alphabetic List (cont.)

ammonium lactate °                                 Anusol-HC # (hydrocortisone) – see Table 16, p. 74
Ammonul (sodium benzoate/sodium                    Anzemet (dolasetron) injection – see Table 27, p. 103
  phenylacetate)                                   Anzemet (dolasetron) tablet – PA; see Table 27,
Amnesteem (isotretinoin) – PA > 21 years; see        p. 103
  Table 10, p. 58                                  APF # (sodium fluoride)
amoxapine – see Table 17, p. 77                    Apidra (insulin glulisine) vial – see Table 45, p. 137
amoxicillin – see Table 35, p. 118                 Apidra (insulin glulisine) prefilled syringe – PA; see
amoxicillin/clavulanate – see Table 35, p. 118       Table 45, p. 137
amoxicillin/clavulanate extended-release – PA;     Aplenzin (bupropion extended-release) – PA; see
  see Table 35, p. 118                               Table 17, p. 77
amoxicillin, extended-release – PA; see            apraclonidine
  see Table 35, p. 118                             aprepitant °
Amoxil # (amoxicillin) – see Table 35, p. 118      Apri (ethinyl estradiol/desogestrel)
amphetamine salts – PA > 90 units/month; see       Apriso (mesalamine extended-release)
  Table 31, p. 111                                 Apokyn (apomorphine)
amphetamine salts extended-release – PA > 60       apomorphine
  units/month; see Table 31, p. 111                Aptivus (tipranavir) – see Table 38, p. 125
amphotericin B                                     Aqua-Mephyton # (phytonadione)
ampicillin – see Table 35, p. 118                  Aralast (alpha1–proteinase inhibitor–human)
ampicillin/sulbactam                               Aralen Hydrochloride (chloroquine)
Ampyra (dalfampridine) – PA                        Aralen Phosphate # (chloroquine)
amrinone                                           Aranelle (ethinyl estradiol/norethindrone)
Amrix (cyclobenzaprine extended-release) – PA;     Aranesp (darbepoetin) – PA; see Table 4, p. 46
  see Table 7, p. 53                               Arava # (leflunomide)
amylase/lipase/protease                            Arcalyst (rilonacept) – PA
Anadrol-50 (oxymetholone)                          Aredia # (pamidronate)
Anafranil # (clomipramine) – see Table 17, p. 77   arformoterol – PA; see Table 23, p. 95
anagrelide                                         argatroban – PA
anakinra – PA; see Table 5, p. 48                  Aricept (donepezil)
AnaMantle HC (hydrocortisone/lidocaine) – PA;      Aricept ODT (donepezil, orally disintegrating tablet) –
  see Table 16, p. 74                                PA
Anamantle HC Forte (hydrocortisone/lidocaine)      Arimidex (anastrozole)
  – PA; see Table 16, p. 74                        aripiprazole injection – see Table 24, p. 97
Anaprox # (naproxen) – see Table 11, p. 61         aripiprazole solution – PA > 750 ml/month; see
Anaspaz # (hyoscyamine)                              Table 24, p. 97
anastrozole                                        aripiprazole tablet – PA > 30 units/month; see
Ancef # (cefazolin)                                  Table 24, p. 97
Ancobon (flucytosine)                              aripiprazole, orally disintegrating tablet – PA; see
Androderm (testosterone)                             Table 24, p. 97
Androgel (testosterone)                            Aristocort (triamcinolone)
Android (methyltestosterone)                       Aristocort # (triamcinolone), topical – see Table 16,
Anexsia # (hydrocodone/acetaminophen) – see          p. 74
  Table 8, p. 55                                   Aristocort A # (triamcinolone) – see Table 16, p. 74
Angeliq (drospirenone/estradiol)                   Aristocort Forte (triamcinolone)
anidulafungin                                      Aristospan (triamcinolone)
Anolor-300 (butalbital/acetaminophen/caffeine)     Arixtra (fondaparinux)
Ansaid # (flurbiprofen) – see Table 11, p. 61      armodafanil – PA
Antabuse (disulfiram) – see Table 36, p. 120       Aromasin (exemestane)
Antara (fenofibrate) – PA see Table 13, p. 66      Arranon (nelarabine) – PA
anthralin                                          Artane # (trihexyphenidyl)
antihemophilic factor, human                       artemether/lumefantrine – PA > 24 units/year
anithemophilic factor, recombinant                 Arthrotec (diclofenac/misoprostol) – PA < 60 years;
anti-inhibitor coagulant complex                     see Table 11, p. 61
antithymocyte globulin, equine – see Table 1,      artificial tears *
  p. 39                                            Arzerra (ofatumumab) – PA
antithymocyte globulin, rabbit – see Table 1,      Asacol (mesalamine, delayed-release tablet)
  p. 39                                            Asacol HD (mesalamine, delayed-release tablet)
Antivert # (meclizine)                             ascorbic acid *


May 3, 2010                                        3
Alphabetic List (cont.)

asenapine – PA; see Table 24, p. 97                 Avinza (morphine extended-release) – PA; see
Asmanex (mometasone) – see Table 23, p. 95            Table 8, p. 55
aspirin *                                           Avita # (tretinoin) – PA > 21 years; see
aspirin/buffers *                                     Table 10, p. 58
Astelin (azelastine) – PA; see Table 12, p. 64      Avodart (dutasteride) – PA
Astepro (azelastine) – PA; see Table 12, p. 64      Avonex (interferon beta-1a)
Astramorph PF (morphine) – see Table 8, p. 55       Axert (almotriptan) – PA; see Table 14, p. 69
Atacand (candesartan) – PA; see Table 18,           Axid (nizatidine) – PA; see Table 3, p. 43
  p. 81                                             Aygestin # (norethindrone)
Atacand HCT (candesartan/hydrochlorothiazide)       azacitidine
  – PA; see Table 18, p. 81                         Azactam (aztreonam)
Atarax # (hydroxyzine) – see Table 12, p. 64        AzaSite (azithromycin, ophthalmic) – PA; see
atazanavir– see Table 38, p. 125                      Table 34, p. 117
atenolol – see Table 21, p. 91                      azathioprine
atenolol/chlorthalidone – see Table 21, p. 91       azelaic acid – PA; see Table 10, p. 58
Atgam (antithymocyte globulin, equine) – see        azelastine inhaler – PA; see Table 12, p. 64
  Table 1, p. 39                                    azelastine ophthalmic – PA; see Table 29, p. 107
Ativan # (lorazepam)                                Azelex (azelaic acid) – PA; see Table 10, p. 58
atomoxetine – PA; see Table 31, p. 111              Azilect (rasagiline)
atorvastatin – PA; see Table 13, p. 66              azithromycin – see Table 35, p. 118
atovaquone                                          azithromycin, ophthalmic – PA; see Table 34, p. 118
atovaquone/proguanil                                Azmacort (triamcinolone) – see Table 23, p. 95
Atripla (efavirenz/emtricitabine/tenofovir) – see   Azopt (brinzolamide)
  Table 38, p. 125                                  Azor (amlodipine/olmesartan) – PA; see
atropine                                              Table 18, p. 81; see Table 22, p. 93
Atrovent HFA (ipratropium), inhaler – see           aztreonam
  Table 23, p. 95                                   Azulfidine # (sulfasalazine)
Atrovent # (ipratropium), inhalation solution –
  see Table 23, p. 95                               B
Atrovent (ipratropium), inhaler – see Table 23,     bacitracin *
  p. 95                                             bacitracin, ophthalmic – see Table 34, p. 117
Atrovent # (ipratropium), nasal spray               bacitracin/polymyxin B
Attenuvax (measles virus vaccine, live) – see       baclofen – see Table 7, p. 53
  Table 32, p. 114                                  baclofen intrathecal – see Table 7, p. 53
augmented betamethasone ° – see Table 16,           Bactrim # (trimethoprim/sulfamethoxazole) – see
  p. 74                                               Table 35, p. 118
Augmentin # (amoxicillin/clavulanate) – see         Bactroban (mupirocin) cream – PA; see Table 41,
  Table 35, p. 118                                    p. 131
Augmentin XR (amoxicillin/clavulanate               Bactroban (mupirocin) nasal ointment – PA; see
  extended-release) – PA; see Table 35,               Table 41, p. 131
  p. 118                                            balsalazide
auranofin                                           Banzel (rufinamide) – PA; see Table 20, p. 86
Aurolate (gold sodium thiomalate)                   Baraclude (entecavir) solution – PA > 600ml/month;
aurothioglucose                                       see Table 44, p. 135
Avalide (irbesartan/hydrochlorothiazide) – PA;      Baraclude (entecavir) tablet – PA > 30 units/month;
  see Table 18, p. 81                                 see Table 44, p. 135
Avandamet (rosiglitazone/metformin) – PA;           BayHep B (hepatitis B immune globulin, human) – see
  see Table 26, p. 101                                Table 1, p. 39
Avandaryl (glimepiride/rosiglitazone) – PA; see     BayRab (rabies immune globulin IM, human) – see
  Table 26, p. 101                                    Table 1, p. 39
Avandia (rosiglitazone) – see Table 26, p. 101      BayRho-D Full Dose (Rho(D) immune globulin IM) –
Avapro (irbesartan) – PA; see Table 18, p. 81         see Table 1, p. 39
Avastin (bevacizumab)                               BayRho-D Mini Dose (Rho(D) immune globulin IM,
AVC # (sulfanilamide)                                 micro-dose) – see Table 1, p. 39
Avelox (moxifloxacin) – see Table 35, p. 118        BayTet (tetanus immune globulin IM, human) – see
Aventyl # (nortriptyline) – see Table 17, p. 77       Table 1, p. 39
Aviane # (ethinyl estradiol/levonorgestrel)         BCG vaccine – see Table 32, p. 114
                                                    Bebulin VH Immuno (factor IX complex)


May 3, 2010                                         4
Alphabetic List (cont.)

becaplermin – PA > 1 tube/month and > 3           Biaxin # (clarithromycin) – see Table 35, p. 118
  tubes/lifetime                                  Biaxin XL (clarithromycin extended-release) – PA; see
beclomethasone, inhaler – see Table 23, p. 95       Table 35, p. 118
beclomethasone, nasal spray – PA; see             bicalutamide
  Table 25, p. 99                                 Bicitra (sodium citrate/citric acid)
Beconase AQ (beclomethasone, nasal spray) –       Bicnu (carmustine)
  PA; see Table 25, p. 99                         BiDil (isosorbide dinitrate/hydralazine) – PA
Benadryl # (diphenhydramine) – see Table 12,      bimatoprost – PA
  p. 64                                           biperiden
benazepril – see Table 18, p. 81                  bisacodyl *
benazepril/hydrochlorothiazide – see Table 18,    bismuth subcitrate/metronidazole/tetracycline – PA;
  p. 81                                             see Table 3, p. 43
bendamustine                                      bismuth subsalicylate *
BeneFix (factor IX, recombinant)                  bismuth subsalicylate/tetracycline/metronidazole – PA;
Benicar (olmesartan) – PA; see Table 18, p. 81      see Table 3, p. 43
Benicar HCT (olmesartan/hydrochlorothiazide) –    bisoprolol – see Table 21, p. 91
  PA; see Table 18, p. 81                         bisoprolol/hydrochlorothiazide – see Table 21, p. 91
Bentyl # (dicyclomine)                            bleomycin
Benzac AC (benzoyl peroxide) – PA; see            Bleph-10 # (sulfacetamide) – see Table 34, p. 117
  Table 10, p. 58                                 Blephamide (sulfacetamide/prednisolone) – see
BenzaClin (benzoyl peroxide/clindamycin) – PA;      Table 34, p. 117
  see Table 10, p. 58                             Blocadren # (timolol) – see Table 21, p. 91
Benzac W (benzoyl peroxide) – PA; see             Boniva (ibandronate) – PA
  Table 10, p. 58                                 Boniva IV (ibandronate) – PA
Benzamycin (benzoyl peroxide/erythromycin) –      Boostrix (diphtheria/tetanus toxoids/acellular pertussis
  PA; see Table 10, p. 58                           vaccine) – see Table 32, p. 114
Benzefoam (benzoyl peroxide foam) – PA; see       bortezomib
  Table 10, p. 58                                 bosentan – see Table 43, p. 133
benzocaine                                        Botox (onabotulinumtoxin A) – PA; see Table 30,
benzoyl peroxide ° – see Table 10, p. 58            p. 109
benzoyl peroxide/clindamycin – PA; see            Brethine # (terbutaline)
  Table 10, p. 58                                 Brevibloc # (esmolol) – see Table 21, p. 91
benzoyl peroxide/erythromycin – PA; see           Brevicon (ethinyl estradiol/norethindrone)
  Table 10, p. 58                                 Brevoxyl (benzoyl peroxide) – PA; see Table 10,
benzoyl peroxide/sulfur – PA; see Table 10,         p. 58
  p. 58                                           brimonidine
benztropine                                       brimonidine/timolol, ophthalmic
benzyl alcohol lotion                             brinzolamide
bepostatine besilate – PA; see Table 29, p. 107   bromfenac – PA
Bepreve (bepotastine besilate) – PA; see          bromocriptine
  Table 29, p. 107                                brompheniramine * – see Table 12, p. 64
besifloxacin – PA; see Table 34, p. 117           brompheniramine/pseudoephedrine * – see
Besivance (besifloxacin) – PA; see Table 34,        Table 12, p. 64
  p. 117                                          Brovana (arformoterol) – PA; see Table 23, p. 95
Betagan # (levobunolol)                           budesonide, inhalation suspension – see Table 23,
betaine                                             p. 95
betamethasone                                     budesonide, inhaler – see Table 23, p. 95
betamethasone, topical ° – see Table 16, p. 74    budesonide, nasal spray – PA; see Table 25, p. 99
betamethasone/calcipotriene – PA                  budesonide/formoterol – PA; see Table 23, p. 95
Betapace # (sotalol) – see Table 21, p. 91        bumetanide
Betaseron (interferon beta 1-b)                   Bumex # (bumetanide)
Beta-Val # (betamethasone) – see Table 16,        Buphenyl (sodium phenylbutyrate)
  p. 74                                           bupivacaine
betaxolol – see Table 21, p. 91                   Buprenex (buprenorphine)
bethanechol                                       buprenorphine ° – see Table 36, p. 120
Betimol (timolol)                                 buprenorphine/naloxone – PA > 32 mg/day; see
bevacizumab                                         Table 36, p. 120
bexarotene                                        buprenorphine/naloxone > 24 and < 32mg/day –
Bexxar (tositumomab) – PA                           PA > 90 days; see Table 36, p. 120

May 3, 2010                                       5
Alphabetic List (cont.)

buprenorphine/naloxone > 16 and < 24 mg/day      canakinumab – PA
  – PA > 180 days; see Table 36, p. 120          Cancidas (caspofungin)
buprenorphine/naloxone < 16 mg/day; see          candesartan – PA; see Table 18, p. 81
  Table 36, p. 120                               candesartan/hydrochlorothiazide – PA; see Table 18,
buprenorphine powder – PA                          p. 81
bupropion – see Table 17, p. 77                  Cantil (mepenzolate)
bupropion extended-release tablets – PA; see     capecitabine
  Table 17, p. 77                                Capex (fluocinolone) – PA; see Table 16, p. 74
bupropion sustained release – see Table 17,      Capitrol (chloroxine)
  p. 77; see Table 6, p. 51                      Capoten # (captopril) – see Table 18, p. 81
Buspar # (buspirone)                             Capozide # (captopril/hydrochlorothiazide) – see
buspirone                                          Table 18, p. 81
butabarbital                                     capsaicin *
butalbital                                       captopril – see Table 18, p. 81
butalbital/acetaminophen                         captopril/hydrochlorothiazide – see Table 18, p. 81
butalbital/acetaminophen/caffeine                Carac (fluorouracil)
butalbital/acetaminophen/codeine/caffeine        Carafate # (sucralfate)
butalbital/aspirin/caffeine                      carbamazepine – see Table 20, p. 86
butalbital/aspirin/codeine/caffeine              carbamide peroxide *
butenafine – PA; see Table 28, p. 105            Carbatrol (carbamazepine) – see Table 20, p. 86
Butisol (butabarbital)                           carbidopa
butoconazole                                     carbidopa/levodopa
butorphanol, injection                           carbidopa/levodopa, orally disintegrating tablet – PA
butorphanol, nasal spray – PA                    carbidopa/levodopa/entacapone – PA
Byetta (exenatide) – PA; see Table 45, p. 137    carbinoxamine – PA; see Table 12, p. 64
Bystolic (nebivolol) – PA; see Table 21, p. 91   carbinoxamine/pseudoephedrine – see
                                                   Table 12, p. 64
C                                                carboplatin
C1 inhibitor, human – PA                         Cardene # (nicardipine) – see Table 22, p. 93
cabergoline                                      Cardizem # (diltiazem) – see Table 22, p. 93
Caduet (amlodipine/atorvastatin) – PA; see       Cardura # (doxazosin) – see Table 19, p. 84
  Table 13, p. 66; see Table 22, p. 93           Cardura XL (doxazosin extended release) – PA; see
Cafcit # (caffeine)                                Table 19, p. 84
caffeine                                         Carimune (immune globulin IV, human) – PA; see
Cafergot # (ergotamine/caffeine)                   Table 1, p. 39
calamine lotion *                                carisoprodol – PA; see Table 7, p. 53
Calan # (verapamil) – see Table 22, p. 93        carisoprodol/aspirin – PA; see Table 7, p. 53
calcifediol                                      carisoprodol/aspirin/codeine) – PA; see Table 7, p. 53
Calciferol (ergocalciferol)                      Carmol HC (hydrocortisone/urea)
Calcijex (calcitriol)                            carmustine
calcipotriene                                    Carnitor # (levocarnitine)
calcitonin, human                                carteolol, oplthalmic
calcitonin, salmon                               Cartia (diltiazem) – see Table 22, p. 93
calcitriol                                       carvedilol – see Table 21, p. 91
calcitrol ointment – PA                          carvedilol extended-release – PA; see Table 21, p. 91
calcium acetate                                  casanthranol *
calcium carbonate *                              Casodex # (bicalutamide)
calcium citrate *                                caspofungin
calcium glubionate *                             Cataflam # (diclofenac) – see Table 11, p. 61
calcium gluconate *                              Catapres # (clonidine)
calcium phosphate *                              Cebocap (lactose)
Calderol (calcifediol)                           Cedax (ceftibuten) – see Table 35, p. 118
           H
Caldolor (ibuprofen injection) – see Table 11,   Ceenu (lomustine)
  p. 61                                          cefaclor – see Table 35, p. 118
CaloMist (cyanocobalamin) – PA                   cefaclor extended-release – PA; see Table 35, p. 118
Campath (alemtuzumab)                            cefadroxil ° – see Table 35, p. 118
Campral (acamprosate) – see Table 36, p. 120     cefazolin
Camptosar # (irinotecan)                         cefdinir – see Table 35, p. 118
                                                 cefditoren – see Table 35, p. 118

May 3, 2010                                      6
Alphabetic List (cont.)

cefepime                                         chlorthalidone
cefixime – see Table 35, p. 118                  chlorzoxazone
Cefizox (ceftizoxime)                            cholestyramine – see Table 13, p. 66
cefotaxime                                       Cibacalcin (calcitonin, human)
cefoxitin                                        ciclesonide – see Table 23, p. 95
cefpodoxime – see Table 35, p. 118               ciclesonide nasal spray – PA; see Table 25, p. 99
cefprozil – see Table 35, p. 118                 ciclopirox ° – see Table 28, p. 105
ceftazidime                                      cidofovir
ceftibuten – see Table 35, p. 118                cilostazol
Ceftin # (cefuroxime) – See Table 35, p. 118     Ciloxan # (ciprofloxacin, ophthalmic solution) – see
ceftizoxime                                         Table 34, p. 117
ceftriaxone                                      Ciloxan (ciprofloxacin, ophthalmic ointment) – PA; see
cefuroxime – see Table 35, p. 118                   Table 34, p. 117
Cefzil # (cefprozil) – see Table 35, p. 118      cimetidine * – see Table 3, p. 43
Celebrex (celecoxib) – PA < 60 years; see        Cimzia (certolizumab) – PA – see Table 5, p. 48
  Table 11, p. 61                                cinacalcet
celecoxib – PA < 60 years; see Table 11, p. 61   Cinobac (cinoxacin)
Celestone (betamethasone)                        cinoxacin
Celexa # (citalopram) – see Table 17, p. 77      Cinryze (C1 inhibitor, human) – PA
Cellcept # (mycophenolate)                       Cipro # (ciprofloxacin) – see Table 35, p. 118
Celontin (methsuximide) – see Table 20, p. 86    Cipro HC (ciprofloxacin/hydrocortisone) – PA
Cenestin (estrogens, conjugated)                 Cipro XR (ciprofloxacin extended-release tablet) – PA;
Centany Kit (mupirocin) – PA                        see Table 35, p. 118
cephalexin ° – see Table 35, p. 118              CiproDex (ciprofloxacin/dexamethasone) – PA
Cephulac # (lactulose)                           ciprofloxacin – see Table 35, p. 118
Ceprotin (protein C concentrate) – PA            ciprofloxacin, extended-release tablet – PA; see
Cerezyme (imiglucerase) – PA                        Table 35, p. 118
  (effective 5/17/10)                            ciprofloxacin OTIC solution – PA
certolizumab – PA – see Table 5, p. 48           ciprofloxacin, ophthalmic solution – see Table 34,
Cerumenex (triethanolamine)                         p. 117
Cervarix (human papillomavirus bivalent          ciprofloxacin, ophthalmic ointment – PA; see
  vaccine) – PA < 10 years and > 25 years;          Table 34, p. 117
  see Table 32, p. 114                           ciprofloxacin/dexamethasone – PA
Cesamet (nabilone) – PA                          ciprofloxacin/hydrocortisone – PA
cetirizine ° – see Table 12, p. 64               cisplatin
Cetraxal (ciprofloxacin OTIC solution) – PA      citalopram – see Table 17, p. 77
cetuximab                                        citrate salts
cevimeline                                       Clarifoam EF (sulfacetamide/sulfur) – PA; see
Chantix (varenicline) – PA > 24 weeks/year;         Table 10, p. 58
  see Table 6, p. 51                             Claforan # (cefotaxime)
Chemet (succimer)                                Claravis (isotretinoin) – PA > 21 years; see
cherry syrup                                        Table 10, p. 58
chloral hydrate                                  Clarinex (desloratadine) – PA; see Table 12, p. 64
chlorambucil                                     Clarinex-D (desloratadine/pseudoephedrine)
chloramphenicol                                     – PA; see Table 12, p. 64
chlordiazepoxide                                 clarithromycin – see Table 35, p. 118
chlorhexidine gluconate *                        clarithromycin extended-release – PA; see Table 35,
chloroquine                                         p. 118
chlorothiazide                                   clemastine – see Table 12, p. 64
chloroxine                                       Cleocin # (clindamycin) – see Table 35, p. 118
chlorpheniramine * – see Table 12, p. 64         Cleocin T # (clindamycin) gel, lotion, solution –
chlorpheniramine/phenylephrine – see Table 12,      PA > 21 years; see Table 10, p. 58
  p. 64                                          Cleocin T (clindamycin) pads – PA; see
chlorpheniramine/pseudoephedrine * – see            Table 10, p. 58
  Table 12, p. 64                                Climara # (estradiol)
chlorpheniramine/pyrilamine/phenylephrine –      Clindagel (clindamycin) – PA; see Table 10, p. 58
  see Table 12, p. 64                            clindamycin ° – see Table 35, p. 118
chlorpromazine                                   clindamycin °, topical – see Table 10, p. 58
chlorpropamide – see Table 26, p. 101

May 3, 2010                                      7
Alphabetic List (cont.)

clindamycin/benzoyl peroxide – PA; see              Combivent (albuterol/ipratropium) – see
   Table 10, p. 58                                    Table 23, p. 95
clindamycin/tretinoin – PA; see Table 10, p. 58     Combivir (lamivudine/zidovudine) – see
Clindesse (clindamycin)                               Table 38, p. 125
Clinoril # (sulindac) – see Table 11, p. 61         Combunox (oxycodone/ibuprofen) – PA; see
clobetasol ° – see Table 16, p. 74                    Table 8, p. 55
Clobex (clobetasol) – PA; see Table 16, p. 74       Commit (nicotine) lozenge – PA > 90 days/treatment
clocortolone – PA; see Table 16, p. 74                regimen and PA > two treatment regimens/year;
Cloderm (clocortolone) – PA; see Table 16,            see Table 6, p. 51
   p. 74                                            Compazine # (prochlorperazine)
clofarabine                                         Compro (prochlorperazine)
Clolar (clofarabine)                                Comtan (entacapone) – PA
clomipramine – see Table 17, p. 77                  Comvax (haemophilus b conjugate/hepatitis b vaccine)
clonazepam – see Table 20, p. 86                      – see Table 32, p. 114
clonazepam, orally disintegrating tablets – PA;     Concerta (methylphenidate extended-release) – PA >
   see Table 20, p. 86                                60 units per month; see Table 31, p. 111
clonidine                                           Condylox (podofilox)
                                                                H
clonidine/chlorthalidone                            conivaptan
clopidogrel                                         Constulose (lactulose)
clorazepate ° – see Table 20, p. 86                 Copaxone (glatiramer)
Clorpres # (clonidine/chlorthalidone)               Copegus # (ribavirin) – see Table 44, p. 135
clotrimazole * – see Table 28, p. 105; see          copper IUD
   Table 47, p. 141                                 Cordarone # (amiodarone)
clotrimazole/betamethasone – see Table 28,          Cordran (flurandrenolide) – PA; see Table 16, p. 74
   p. 105                                           Coreg # (carvedilol) – see Table 21, p. 91
clozapine – see Table 24, p. 97                     Coreg CR (carvedilol extended-release) – PA; see
clozapine, orally disintegrating tablet – PA; see     Table 21, p. 91
   Table 24, p. 97                                  Corgard # (nadolol) – see Table 21, p. 91
Clozaril # (clozapine) – see Table 24, p. 97        Cormax # (clobetasol) – see Table 16, p. 74
coal tar °                                          Cortef # (hydrocortisone)
Coartem (artemether/lumefantrine) – PA > 24         corticotrophin – PA
   units/year                                       Cortifoam (hydrocortisone)
cod liver oil *                                     cortisone
codeine – PA > 360 mg/day; see Table 8, p. 55       Cortisporin #, ophthalmic (neomycin/polymyxin/
codeine powder – PA; see Table 8, p. 55               hydrocortisone) – see Table 34, p. 117
codeine/acetaminophen – see Table 8, p. 55          Cortisporin # (neomycin/polymyxin/
codeine/aspirin – see Table 8, p. 55                  hydrocortisone)
Cogentin # (benztropine)                            Cortisporin-TC (colistin/hydrocortisone/neomycin)
Cognex (tacrine)                                    Cortomycin (neomycin/polymyxin B/
Colazal # (balsalazide)                               hydrocortisone) – see Table 34, p. 117
colchicine/probenecid                               Cortrosyn (cosyntropin)
colesevelam, powder for suspension – PA;            Corzide # (nadolol/bendroflumethiazide) – see
   see Table 13, p. 66                                Table 21, p. 91
colesevelam, tablet – PA (effective 5/17/10);       Cosopt # (dorzolamide/timolol)
   see Table 13, p. 66; see Table 26, p. 101        cosyntropin
Colestid # (colestipol) – see Table 13, p. 66       Coumadin # (warfarin)
colestipol – see Table 13, p. 66                    Covera-HS (verapamil) – see Table 22, p. 93
colistimethate                                      Cozaar (losartan) – PA; see Table 18, p. 81
colistin/hydrocortisone/neomycin                    Creon (amylase/lipase/protease)
collagenase                                         Crestor (rosuvastatin) – PA; see Table 13, p. 66
colloidal oatmeal *                                 Crixivan (indinavir) – see Table 38, p. 125
Col-Probenecid # (colchicine/probenecid)            Crolom # (cromolyn) – see Table 29, p. 107
Coly-Mycin (colistimethate)                         cromolyn
CoLyte # (polyethylene glycol-electrolyte           cromolyn ophthalmic – see Table 29, p. 107
   solution)                                        crotamiton
Combigan (brimonidine/timolol, ophthalmic)          Cubicin (daptomycin)
Combipatch (estradiol/norethindrone)                Cuprimine (penicillamine)
Combipres (clonidine/chlorthalidone)                Cutivate # (fluticasone) – see Table 16, p. 74


May 3, 2010                                         8
Alphabetic List (cont.)

Cutivate (fluticasone) lotion – PA; see Table 16,   Daraprim (pyrimethamine)
  p. 74                                             darbepoetin alpha – PA; see Table 4, p. 46
cyanocobalamin °                                    darifenacin 7.5 mg – PA > 30 units/month; see
cyanocobalamin/folic acid – PA                        Table 46, p. 139
Cyclessa # (ethinyl estradiol/desogestrel)          darifenacin 15 mg – see Table 46, p. 139
cyclobenzaprine° – see Table 7, p. 53               darunavir – see Table 38, p. 125
cyclobenzaprine extended-release – PA; see          Darvocet-N # (propoxyphene napsylate/
  Table 7, p. 53                                      acetaminophen) – see Table 8, p. 55
Cyclocort # (amcinonide) – see Table 16, p. 74      Darvon # (propoxyphene) – see Table 8, p. 55
Cyclogyl # (cyclopentolate)                         Darvon-N (propoxyphene napsylate) – see Table 8,
Cyclomydril (cyclopentolate/phenylephrine)            p. 55
cyclopentolate                                      dasatinib
cyclopentolate/phenylephrine                        Daypro # (oxaprozin) – see Table 11, p. 61
cyclophosphamide                                    Daytrana (methylphenidate transdermal system) – PA;
cyclosporine                                          see Table 31, p. 111
cyclosporine, ophthalmic – PA > 64                  Dazidox (oxycodone immediate release) – PA; see
  units/month                                         Table 8, p. 55
                                 H
Cyklokapron (tranexamic acid)                       DDAVP # (desmopressin)
Cymbalta (duloxetine) – PA; see Table 17, p. 77     Deca-Durabolin (nandrolone)
cyproheptadine – see Table 12, p. 64                Decavac (diphtheria/tetanus toxoid vaccine) – see
Cystadane (betaine)                                   Table 32, p. 114
Cystagon (cysteamine)                               decitabine
cysteamine                                          Declomycin # (demeclocycline) – see Table 35, p. 118
Cystospaz # (hyoscyamine)                           deferasirox
Cytadren (aminoglutethimide)                        deferoxamine
cytarabine                                          degarelix – PA; see Table 2, p. 41
CytoGam (cytomegalovirus immune globulin IV,        Delatestryl (testosterone)
  human) – see Table 1, p. 39                       delavirdine – see Table 38, p. 125
cytomegalovirus immune globulin IV, human –         Delestrogen # (estradiol)
  see Table 1, p. 39                                Deltasone # (prednisone)
Cytomel # (liothyronine)                            Demadex # (torsemide)
Cytosar-U # (cytarabine)                            demeclocycline – see Table 35, p. 118
Cytotec # (misoprostol)                             Demerol (meperidine) – PA; see Table 8, p. 55
Cytovene (ganciclovir)                              Demser (metyrosine)
Cytoxan # (cyclophosphamide)                        Demulen # (ethinyl estradiol/ethynodiol)
Cytra-2 (sodium citrate/citric acid)                Denavir (penciclovir)
Cytra-3 (potassium citrate/sodium citrate/citric    Depacon (valproate) – see Table 20, p. 86
  acid)                                             Depakene # (valproic acid) – see Table 20, p. 86
Cytra-K (potassium citrate/citric acid)             Depakote # (divalproex) – see Table 20, p. 86
                                                    Depen (penicillamine)
D                                                   Deplin (L-methylfolate) – PA
                                                    Depo-Estradiol (estradiol)
dacarbazine
                                                    Depo-Medrol # (methylprednisolone)
daclizumab
                                                    Depo-SubQ Provera 104 (medroxyprogesterone)
Dacogen (decitabine)
                                                    Deponit (nitroglycerin)
dalfampridine – PA
                                                    Depo-Provera # (medroxyprogesterone)
dalfopristin/quinpristin
                                                    Depo-Testosterone # (testosterone)
Dalmane # (flurazepam) – PA > 30
                                                    Derma-Smoothe/FS (fluocinolone) – PA; see
  units/month; see Table 15, p. 72
                                                      Table 16, p. 74
dalteparin
                                                    Dermatop # (prednicarbate) – see Table 16, p. 74
danazol
                                                    DermOtic (fluocinolone) – see Table 16, p. 74
Danocrine # (danazol)
                                                    Desferal # (deferoxamine)
Dantrium # (dantrolene)
                                                    desipramine – see Table 17, p. 77
dantrolene
                                                    desloratadine – PA; see Table 12, p. 64
dapsone – see Table 35, p. 118
                                                    desloratadine/pseudoephedrine – PA; see
dapsone gel – PA; see Table 10, p. 58
                                                      Table 12, p. 64
Daptacel (diphtheria/tetanus toxoids/acellular
                                                    desmopressin
  pertussis vaccine) – see Table 32, p. 114
                                                    Desogen # (ethinyl estradiol/desogestrel)
daptomycin
                                                    Desonate (desonide) – PA; see Table 16, p. 74

May 3, 2010                                         9
Alphabetic List (cont.)

desonide ° – see Table 16, p. 74                  Didronel # (etidronate)
DesOwen # (desonide) – see Table 16, p. 74        Differin (adapalene) – PA; see Table 10, p. 58
desoximetasone – see Table 16, p. 74              diflorasone – see Table 16, p. 74
Desoxyn (methamphetamine) – PA                    Diflucan # (fluconazole) – see Table 47, p. 141
Desquam (benzoyl peroxide) – PA; see              diflunisal – see Table 11, p. 61
  Table 10, p. 58                                 difluprednate – PA
desvenlafaxine – PA; see Table 17, p. 77          Digitek (digoxin)
Detrol (tolterodine) – see Table 46, p. 139       digoxin
Detrol LA 2 mg (tolterodine extended-release) –   dihydrocodeine/aspirin/caffeine
  PA > 30 units/month; see Table 46, p. 139       dihydroergotamine – PA
Detrol LA 4 mg (tolterodine extended-release) –   dihydrotachysterol
  see Table 46, p. 139                            Dilacor # (diltiazem) – see Table 22, p. 93
dexamethasone °                                   Dilantin Infatab (phenytoin) – see Table 20, p. 86
dexamethasone intravitreal implant ^              Dilantin # (phenytoin) capsule, kapseal, suspension –
dexamethasone/neomycin                               see Table 20, p. 86
Dexasporin (neomycin/polymyxin B/                 Dilatrate-SR (isosorbide)
  dexamethasone)                                  Dilaudid # (hydromorphone) – PA > 60 mg/day; see
dexbrompheniramine/pseudoephedrine – see             Table 8, p. 55
  Table 12, p. 64                                 diltiazem – see Table 22, p. 93
dexchlorpheniramine – see Table 12, p. 64         Diovan (valsartan) – PA; see Table 18, p. 81
Dexedrine # (dextroamphetamine) –                 Diovan HCT (valsartan/hydrochlorothiazide) – PA; see
  PA > 90 units/month; see Table 31, p. 111          Table 18, p. 81
Dexferrum (iron dextran)                          Dipentum (olsalazine)
Dexilant (dexlansoprazole) – PA; see Table 3,     diphenhydramine * – see Table 12, p. 64
  p. 43                                           diphenhydramine/pseudoephedrine * – see
dexlansoprazole – PA; see Table 3, p. 43             Table 12, p. 64
dexmethylphenidate – PA > 90 units/month;         diphenoxylate/atropine
  see Table 31, p. 111                            dipivefrin
dexmethylphenidate extended-release – PA          Diprolene # (betamethasone) – see Table 16, p. 74
  > 60 units/month; see Table 31, p. 111          Diprolene AF # (augmented betamethasone) – see
DexPak (dexamethasone) – PA                          Table 16, p. 74
dexrazoxane                                       diphtheria/tetanus toxoids/acellular
dextroamphetamine – PA > 90 units/month;             pertussis/haemophilus b conjugate vaccine – see
  liquid formulation, PA > 450 ml/month; see         Table 32, p. 114
  Table 31, p. 111                                diphtheria/tetanus toxoids/acellular pertussis/hepatitis
dextrose                                             B, recombinant/poliovirus, inactivated vaccine – see
Dextrostat # (dextroamphetamine) – PA > 90           Table 32, p. 114
  units/month; see Table 31, p. 111               diphtheria/tetanus toxoids/acellular pertussis vaccine –
D.H.E. 45 (dihydroergotamine mesylate)               see Table 32, p. 114
DHT (dihydrotachysterol)                          diphtheria/tetanus toxoids/acellular
DiaBeta (glyburide) – PA; see Table 26, p. 101       pertussis/poliovirus, inactivated/haemophilus b
Diabinese # (chlorpropamide) – see Table 26,         conjugate vaccine – see Table 32, p. 114
  p. 101                                          diphtheria/tetanus toxoids/acellular
Diamox # (acetazolamide)                             pertussis/poliovirus, inactivated vaccine – see
Diastat (diazepam rectal gel) – PA > 5 kits (10      Table 32, p. 114
  syringes)/month; see Table 20, p. 86            diphtheria/tetanus toxoid vaccine – see Table 32,
diazepam – see Table 7, p. 53; see Table 20,         p. 114
  p. 86                                           dipyridamole
diazepam powder – PA; see Table 20, p. 86         dipyridamole/aspirin
diazepam rectal gel – PA > 5 kits (10             Diquinol (iodoquinol)
  syringes/month); see Table 20, p. 86            disopyramide
diazoxide                                         disulfiram – see Table 36, p. 120
diclofenac ° – see Table 11, p. 61                Ditropan # (oxybutynin) – see Table 46, p. 139
diclofenac/misoprostol – PA < 60 years; see       Ditropan XL # (oxybutynin extended-release) – see
  Table 11, p. 61                                    Table 46, p. 139
dicloxacillin – see Table 35, p. 118              Diuril # (chlorothiazide)
dicyclomine                                       divalproex – see Table 20, p. 86
didanosine – see Table 38, p. 125                 Divigel (estradiol)
                                                  docetaxel

May 3, 2010                                       10
Alphabetic List (cont.)

docusate sodium *                                E
dofetilide
                                                 echothiophate iodine
dolasetron injection – see Table 27, p. 103
                                                 econazole – see Table 28, p. 105
dolasetron tablet – PA; see Table 27, p. 103
                                                 Econopred # (prednisolone)
Dolobid # (diflunisal) – see Table 11, p. 61
                                                 eculizumab – PA
Dolophine # (methadone) – PA > 120 mg/day;
                                                 Edecrin (ethacrynic acid)
  see Table 8, p. 55
                                                 Edluar (zolpidem sublingual) – PA; see
Domeboro # (aluminum acetate)
                                                   Table 15, p. 72
donepezil
                                                 efavirenz – see Table 38, p. 125
donepezil, orally disintegrating tablet – PA
                                                 efavirenz/emtricitabine/tenofovir – see Table 38,
Doral (quazepam) – PA; see Table 15, p. 72
                                                   p. 125
Doribax (doripenem)
                                                 Effexor # (venlafaxine) – see Table 17, p. 77
doripenem
                                                 Effexor XR (venlafaxine extended-release) – PA; see
dornase alpha
                                                   Table 17, p. 77
Doryx (doxycycline) – PA; see Table 35, p. 118
                                                 Effient (prasugrel)
dorzolamide
                                                 Efudex (fluorouracil)
dorzolamide/timolol
                                                 Efudex occlusion pack (fluorouracil) – PA
Dostinex # (cabergoline)
                                                 Elaprase (idursulfase) – PA
Dovonex (calcipotriene)
                                                 Eldepryl # (selegiline)
doxazosin – see Table 19, p. 84
                                                 electrolyte solution, pediatric *
doxazosin extended release – PA; see Table 19,
                                                 Elestat (epinastine) – PA; see Table 29, p. 107
  p. 84
                                                 Elestrin (estradiol)
doxepin – see Table 17, p. 77
                                                 eletriptan – PA; see Table 14, p. 69
doxercalciferol
                                                 Elidel (pimecrolimus) – PA; see Table 42, p. 132
doxorubicin
                                                 Eligard (leuprolide) – PA; see Table 2, p. 41
doxycycline ° – see Table 10, p. 58; see
                                                 Elimite # (permethrin)
  Table 35, p. 118
                                                 Elitek (rasburicase)
Drisdol # (ergocalciferol)
                                                 Elixophyllin-KI (theophylline/potassium iodide)
dronabinol – PA
                                                 Ellence (epirubicin)
dronedarone
                                                 Elmiron (pentosan)
droperidol
                                                 Elocon # (mometasone) – see Table 16, p. 74
drospirenone/estradiol
                                                 Eloxatin (oxaliplatin)
Droxia (hydroxyurea)
                                                 eltrombopag – PA
DTIC-Dome # (dacarbazine)
                                                 Emadine (emedastine) – PA; see Table 29, p. 107
Duac (benzoyl peroxide/clindamycin) – PA; see
                                                 Embeda (morphine/naloxone) – PA; see Table 8,
  Table 10, p. 58
                                                   p. 55
Duetact (glimepiride/pioglitazone) – PA; see
                                                 Embeline # (clobetasol) – see Table 16, p. 74
  Table 26, p. 101
                                                 Emcyt (estramustine)
duloxetine – PA; see Table 17, p. 77
                                                 emedastine – PA; see Table 29, p. 107
DuoNeb # (albuterol/ipratropium) – see
                                                 Emend (aprepitant) 80 mg, 125 mg – PA > 3 units/14
  Table 23, p. 95
                                                   days
Duphalac (lactulose)
                                                 Emend (aprepitant) 40 mg – PA > 1 capsule/Rx and
Duragesic (fentanyl transdermal system) – PA;
                                                   PA > 3 capsules/month
  see Table 8, p. 55
                                                 Emend (fosaprepitant), injection
Duramorph (morphine) – see Table 8, p. 55
                                                 Emend Tri-fold (aprepitant)
Durezol (difluprednate) – PA
                                                 EMLA # (lidocaine/prilocaine) – PA > 1 tube/month
Duricef # (cefadroxil) – see Table 35, p. 118
                                                   and PA > 3 months
dutasteride – PA
                                                 EMSAM (selegiline transdermal system) – PA; see
Dyazide # (triamterene/hydrochlorothiazide)
                                                   Table 17, p. 77
Dynacin # (minocycline) – see Table 35, p. 118
                                                 emtricitabine – see Table 38, p. 125
Dynacirc # (isradipine) – see Table 22, p. 93
                                                 emtricitabine/tenofovir – see Table 38, p. 125
Dynacirc CR (isradipine extended-release) –
                                                 Emtriva (emtricitabine) – see Table 38, p. 125
  PA; see Table 22, p. 93
                                                 E-Mycin # (erythromycin) – see Table 35, p. 118
Dynapen (dicloxacillin) – see Table 35, p. 118
                                                 Enablex 7.5 mg (darifenacin) – PA > 30 units/month;
Dyphylline-GG (dyphylline/guaifenesin)
                                                   see Table 46, p. 139
dyphylline/guaifenesin
                                                 Enablex 15 mg (darifenacin) – see Table 46, p. 139
Dysport (abobotulinumtoxin A) – PA; see
                                                 enalapril – see Table 18, p. 81
  Table 30, p. 109
                                                 enalapril/hydrochlorothiazide – see Table 18, p. 81


May 3, 2010                                      11
Alphabetic List (cont.)

Enbrel (etanercept) – PA; see Table 5, p. 48     Ery Pad (erythromycin) – PA; see Table 10, p. 58
Endocet (oxycodone/acetaminophen) – see          Eryped # (erythromycin) – see Table 35, p. 118
  Table 8, p. 55                                 Ery-tab (erythromycin) – see Table 35, p. 118
Endocodone (oxycodone) – PA > 240 mg/day;        Erythrocin (erythromycin) – see Table 35, p. 118
  see Table 8, p. 55                             erythromycin – see Table 10, p. 58; see
Endodan (oxycodone/aspirin) – see Table 8,         Table 35, p. 118
  p. 55                                          erythromycin °, topical – see Table 10, p. 58
Enduron # (methyclothiazide)                     erythromycin, ophthalmic – see Table 34, p. 117
Enduronyl (methyclothiazide/deserpidine)         escitalopram – PA; see Table 17, p. 77
Enemeez enema (docusate)                         Esclim # (estradiol)
enfuvirtide – see Table 38, p. 125               Esgic # (butalbital/acetaminophen/caffeine)
Engerix-B (hepatitis B, recombinant vaccine) –   Eskalith # (lithium)
  see Table 32, p. 114                           esmolol – see Table 21, p. 91
Enjuvia (estrogens, conjugated)                  esomeprazole – PA; see Table 3, p. 43
enoxaparin                                       estazolam – PA > 30 units/month; see
Enpresse (levonorgestrel/ethinyl estradiol)        Table 15, p. 72
entacapone – PA                                  Estrace # (estradiol)
entecavir solution – PA > 600ml/month; see       Estraderm (estradiol)
  Table 44, p. 135                               estradiol
entecavir tablet – PA > 30 units/month; see      estradiol/medroxyprogesterone
  Table 44, p. 135                               estradiol/norethindrone
         H
Enterg (alvimopan)                               estramustine
Entocort (budesonide)                            Estrasorb (estradiol)
Enulose (lactulose)                              Estring (estradiol)
Epiduo (adapalene/benzoyl peroxide) – PA; see    estriol
  Table 10, p. 58                                estrogens, conjugated
Epifoam (hydrocortisone/pramoxine)               estrogens, conjugated/medroxyprogesterone
Epifrin # (epinephrine)                          estrogens, esterified
epinastine – PA; see Table 29, p. 107            estropipate
epinephrine                                      Estrostep Fe # (ethinyl estradiol/norethindrone)
Epipen (epinephrine)                             eszopiclone – PA; see Table 15, p. 72
epirubicin                                       etanercept – PA; see Table 5, p. 48
Epitol (carbamazepine) – see Table 20, p. 86     ethacrynic acid
Epivir (lamivudine) – see Table 38, p. 125       ethambutol
Epivir HBV (lamivudine) solution – PA > 600      ethinyl estradiol/desogestrel
  ml/month; see Table 44, p. 135                 ethinyl estradiol/drospirenone
Epivir HBV (lamivudine) tablet – PA > 30         ethinyl estradiol/ethynodiol
  units/month; see Table 44, p. 135              ethinyl estradiol/levonorgestrel
eplerenone – PA – see Table 33, p. 116           ethinyl estradiol/norelgestromin
epoetin alfa – PA; see Table 4, p. 46            ethinyl estradiol/norethindrone
Epogen (epoetin alfa) – PA; see Table 4, p. 46   ethinyl estradiol/norgestimate
epoprostenol – see Table 43, p. 133              ethinyl estradiol/norgestrel
eprosartan – PA; see Table 18, p. 81             ethosuximide – see Table 20, p. 86
eprosartan/hydrochlorothiazide – PA; see         ethotoin – see Table 20, p. 86
  Table 18, p. 81                                etidronate
Epzicom (abacavir/lamivudine) – see Table 38,    etodolac ° – see Table 11, p. 61
  p. 125                                         etonogestrel/ethinyl estradiol
Equagesic (meprobamate/aspirin)                  etonogestrel implant
Equetro (carbamazepine) – see Table 20, p. 86    etoposide
Eraxis (anidulafungin)                           etravirine – see Table 38, p. 125
Erbitux (cetuximab)                              Eulexin # (flutamide)
ergocalciferol                                   Eurax (crotamiton)
ergoloid                                         Evamist (estradiol)
ergotamine/caffeine                              everolimus 5 mg – PA > 30 units/month
erlotinib                                        everolimus 10 mg
Errin (norethindrone)                            Evista (raloxifene)
Ertaczo (sertaconazole) – PA; see Table 28,      Evoclin (clindamycin) – PA; see Table 10, p. 58
  p. 105                                         Evoxac (cevimeline)
ertapenem                                        Exelderm (sulconazole) – PA; see Table 28, p. 105

May 3, 2010                                      12
Alphabetic List (cont.)

Exelon (rivastigmine)                                 Ferrlecit (sodium ferric gluconate complex)
exemestane                                            ferrous fumarate *
exenatide – PA; see Table 45, p. 137                  ferrous gluconate *
Exforge (amlodipine/valsartan) – PA; see              ferrous sulfate *
  Table 18, p. 81; see Table 22, p. 93                ferumoxytol
Exforge HCT                                           fesoterodine 4 mg – PA > 30 units/month; see
  (amlodipine/valsartan/hydrochlorothiazide) –           Table 46, p. 139
  PA; see Table 18, p. 81                             fesoterodine 8 mg – see Table 46, p. 139
Exjade (deferasirox)                                  Fexmid (cyclobenzaprine) – PA; see Table 7, p. 53
Extina (ketoconazole) – PA; see Table 28,             fexofenadine – PA; see Table 12, p. 64
  p. 105                                              fexofenadine orally disintegrating tablet – PA; see
ezetimibe – PA; see Table 13, p. 66                      Table 12, p. 64
ezetimibe/simvastatin – PA; see Table 13, p. 66       fexofenadine/pseudoephedrine – PA; see
                                                         Table 12, p. 64
F                                                     Fibricor (fenofibric acid) – PA; see Table 13, p. 66
Fabrazyme (agalsidase) – PA                           fibrinogen concentrate
Factive (gemifloxacin) – see Table 35, p. 118         filgrastim – see Table 4, p. 46
factor IX complex                                     Finacea (azelaic acid) – PA; see Table 10, p. 58
factor IX, human                                      finasteride – PA
factor IX, recombinant                                Fioricet # (butalbital/acetaminophen/caffeine)
famciclovir                                           Fioricet/codeine # (butalbital/acetaminophen/
famotidine * – see Table 3, p. 43                        codeine/caffeine)
Famvir # (famciclovir)                                Fiorinal # (butalbital/aspirin/caffeine)
Fanapt (iloperidone) – PA; see Table 24, p. 97        Fiorinal/codeine # (butalbital/codeine/aspirin/
Fareston (toremifene)                                    caffeine)
Faslodex (fulvestrant) – PA                           Firmagon (degarelix) – PA; – see Table 2, p. 41
fat emulsion, intravenous                             Flagyl # (metronidazole) – see Table 35, p. 118
Fazaclo (clozapine, orally disintegrating tablet) –   Flagyl ER (metronidazole extended-release) – PA; see
  PA; see Table 24, p. 97                                Table 35, p. 118
febuoxstat – PA                                       Flarex # (fluorometholone)
Feiba VH Immuno (anti-inhibitor coagulant             flavoxate – see Table 46, p. 139
  complex)                                            Flebogamma (immune globulin IV, human) – PA; see
felbamate – see Table 20, p. 86                          Table 1, p. 39
Felbatol (felbamate) – see Table 20, p. 86            flecanide
Feldene # (piroxicam) – see Table 11, p. 61           Flector Patch (diclofenac topical patch) – PA; see
felodipine – see Table 22, p. 93                         Table 11, p. 61
Femara (letrozole)                                    Flexeril # (cyclobenzaprine) – see Table 7, p. 53
Femhrt (ethinyl estradiol/norethindrone)              Flolan # (epoprostenol) – see Table 43, p. 133
Femring (estradiol)                                   Flomax (tamsulosin) – PA; see Table 19, p. 84
Femtrace (estradiol)                                  Flonase # (fluticasone), nasal spray – PA > 1
fenofibrate ° – see Table 13, p. 66                      inhaler/month; see Table 25, p. 99
fenofibric acid – PA; see Table 13, p. 66             Florinef # (fludrocortisone)
Fenoglide (fenofibrate) – PA; see Table 13,           flouormetholone
  p. 66                                               Flovent (fluticasone) – see Table 23, p. 95
fenoprofen 200 mg, 400 mg – PA; see Table 11,         Flovent HFA (fluticasone) – see Table 23, p. 95
  p. 61                                               Floxin # (ofloxacin) – see Table 35, p. 118
fenoprofen 600 mg – see Table 11, p. 61               Floxin Otic (ofloxacin, otic solution)
fentanyl buccal film – PA; see Table 8, p. 55         Floxin Otic Singles (ofloxacin, otic solution) – PA
fentanyl buccal tablet – PA; see Table 8, p. 55       Fluarix (influenza virus vaccine) – see Table 32,
fentanyl, injection – see Table 8, p. 55                 p. 114
fentanyl powder – PA; see Table 8, p. 55              fluconazole – see Table 47, p. 141
fentanyl transdermal system – PA; see Table 8,        flucytosine – see Table 47, p. 141
  p. 55                                               fludaribine
fentanyl, transmucosal system – PA; see               fludrocortisone
  Table 8, p. 55                                      FluLaval (influenza virus vaccine) – see
Fentora (fentanyl buccal tablet) – PA; see               Table 32, p. 114
  Table 8, p. 55                                      Flumadine # (rimantadine)
Feraheme (ferumoxytol)                                Flumist (influenza virus vaccine live, intranasal) – PA >
                                                         1 dose/season; see Table 32, p. 114

May 3, 2010                                           13
Alphabetic List (cont.)

flunisolide, inhaler – see Table 23, p. 95           Formaldehyde-10 (formaldehyde)
flunisolide, ° nasal spray – PA > 1                  formoterol – PA; see Table 23, p. 95
   inhaler/month; see Table 25, p. 99                Fortamet (metformin extended-release) – PA; see
fluocinolone ° – see Table 16, p. 74                    Table 26, p. 101
fluocinonide ° – see Table 16, p. 74                 Fortaz (ceftazidime)
fluorides                                            Forteo (teriparatide) – PA
Fluoritab (sodium fluoride)                          Fortical (calcitonin, salmon)
fluorometholone                                      Fosamax (alendronate) solution – PA
fluorometholone/sulfacetamide – see Table 34,           (effective 5/17/10)
   p. 117                                            Fosamax # (alendronate) tablet
Fluor-op (fluorometholone)                           Fosamax Plus D (alendronate/vitamin D3) – PA
Fluoroplex (fluorouracil)                            fosamprenavir – see Table 38, p. 125
fluorouracil °                                       fosaprepitant
fluoxetine ° – see Table 17, p. 77                   foscarnet
fluoxetine/olanzapine – PA; see Table 17, p. 77;     fosfomycin – see Table 35, p. 118
   see Table 24, p. 97                               fosinopril – see Table 18, p. 81
fluoxymesterone                                      fosinopril/hydrochlorothiazide – see Table 18, p. 81
fluphenazine                                         Fosrenol (lanthanum)
flurandrenolide – PA; see Table 16, p. 74            Fragmin (dalteparin)
flurazepam – PA > 30 units/month; see                Frova (frovatriptan) – PA; see Table 14, p. 69
   Table 15, p. 72                                   frovatriptan – PA; see Table 14, p. 69
flurbiprofen – see Table 11, p. 61                   fulvestrant – PA
flutamide                                            Fulvicin # (griseofluvin) – see Table 47, p. 141
fluticasone furoate, nasal spray – PA; see           Furadantin (nitrofurantoin) – see Table 35, p. 118
   Table 25, p. 99                                   furosemide
fluticasone, inhalation – see Table 23, p. 95        Fusilev (levoleucovorin) – PA
fluticasone propionate, nasal spray – PA > 1         Fuzeon (enfuvirtide) – see Table 38, p. 125
   inhaler/month; see Table 25, p. 99
fluticasone, topical ° – see Table 16, p. 74         G
fluticasone/salmeterol – PA; see Table 23, p. 95     gabapentin – see Table 20, p. 86
fluvastatin – PA; see Table 13, p. 66                gabapentin powder – PA > 18 years; see
fluvastatin extended-release – PA; see                 Table 20, p. 86
   Table 13, p. 66                                   Gabitril (tiagabine) – PA > 18 years; see
Fluvirin (influenza virus vaccine) – see Table 32,     Table 20, p. 86
   p. 114                                            galantamine
fluvoxamine – see Table 17, p. 77                    galantamine, extended-release capsule
fluvoxamine extended-release – PA; see               galsulfase – PA
   Table 17, p. 77                                   Gamimune N (immune globulin IV, human) – PA; see
Fluzone (influenza virus vaccine) – see                Table 1, p. 39
   Table 32, p. 114                                  Gammagard S/D (immune globulin IV, human) – PA;
Fluzone HD (influenza virus vaccine, high dose)        see Table 1, p. 39
   – PA < 65 years; see Table 32, p. 114             Gammar-P IV (immune globulin IV, human) – PA; see
FML # (fluorometholone)                                Table 1, p. 39
FML-S (fluorometholone/sulfacetamide) – see          Gamulin Rh (Rho (D) immune globulin IM) – see
   Table 34, p. 117                                    Table 1, p. 39
Focalin # (dexmethylphenidate) – PA > 90             Gamunex (immune globulin IV, human) – PA; see
   units/month; see Table 31, p. 111                   Table 1, p. 39
Focalin XR (dexmethylphenidate extended-             ganciclovir
   release) – PA > 60 units/month; see               Gantrisin (sulfisoxazole) – see Table 35, p. 118
   Table 31, p. 111                                  Gardasil (human papillomavirus quadrivalent vaccine)
folic acid *                                           – PA < 9 years and > 26 years; see Table 32,
folic acid/multivitamin – PA                           p. 114
folic acid/multivitamin/saw palmetto – PA            Gastrocrom (cromolyn)
Folotyn (pralatrexate)                               gatifloxacin
Foltrate (cyanocobalamin/folic acid) – PA            gatifloxacin, ophthalmic – PA; see Table 34, p. 117
fondaparinux                                         gefitinib
Foradil (formoterol) – PA; see Table 23, p. 95       gelatin
formaldehyde                                         Gelnique (oxybutynin gel) – PA; see Table 46, p. 139


May 3, 2010                                          14
Alphabetic List (cont.)

gemcitabine                                        Grifulvin # (griseofulvin) – see Table 47, p. 141
gemfibrozil – see Table 13, p. 66                  griseofulvin – see Table 47, p. 141
gemifloxacin – see Table 35, p. 118                Gris-Peg # (griseofulvin) – see Table 47, p. 141
gemtuzumab                                         guaifenesin/dyphylline
Gemzar (gemcitabine)                               guanabenz
Gengraf (cyclosporine)                             guanfacine
Genoptic # (gentamicin sulfate) – see Table 34,    guanfacine extended-release – see Table 31, p. 111
   p. 117                                          Gynazole-1 (butoconazole)
Genora (ethinyl estradiol/norethindrone)           Gynodiol (estradiol)
Genotropin (somatropin) – PA; see Table 9,
   p. 56                                           H
Gentak # (gentamicin) – see Table 34, p. 117       haemophilus b conjugate/hepatitis b vaccine – see
gentamicin                                           Table 32, p. 114
gentamicin, ophthalmic – see Table 34, p. 117      haemophilus b conjugate vaccine – see
Geodon (ziprasidone) – PA > 60 units/month;          Table 32, p. 114
   see Table 24, p. 97                             HalfLytely (polyethylene glycol-electrolyte
Geodon (ziprasidone), injection – see Table 24,      solution/bisacodyl) – PA
   p. 97                                           halcinonide – PA; see Table 16, p. 74
glatiramer                                         Haldol # (haloperidol)
Gleevec (imatinib)                                 halobetasol – see Table 16, p. 74
glimepiride – see Table 26, p. 101                 Halog (halcinonide) – PA; see Table 16, p. 74
glimepiride/pioglitazone – PA; see Table 26,       Halog-E (halcinonide) – PA; see Table 16, p. 74
   p. 101                                          Haloperidol
glimepiride/rosiglitazone – PA; see Table 26,      haloprogin – PA; see Table 28, p. 105
   p. 101                                          Halotin (haloprogin) – PA; see Table 28, p. 105
glipizide – see Table 26, p. 101                   Havrix (hepatitus A vaccine, inactivated) – see
glipizide extended-release – see Table 26,           Table 32, p. 114
   p. 101                                          HBIG (hepatitis B immune globulin, human) – see
glipizide/metformin – PA; see Table 26, p. 101       Table 1, p. 39
glucagon                                           Hectorol (doxercalciferol)
Glucophage # (metformin) – see Table 26,           Helidac (bismuth subsalicylate/tetracycline/
   p. 101                                            metronidazole) – PA; see Table 3, p. 43
Glucophage XR # (metformin extended-release)       Helixate (antithemophilic factor, recombinant)
   – see Table 26, p. 101                          Hemofil-M (antithemophilic factor, recombinant)
Glucotrol # (glipizide) – see Table 26, p. 101     Hep-Lock # (heparin)
Glucotrol XL # (glipizide extended-release) –      heparin
   see Table 26, p. 101                            heparin lock flush
Glucovance (glyburide/metformin) – PA;             hepatitis A vaccine, inactivated – see Table 32, p. 114
   see Table 26, p. 101                            hepatitis A vaccine inactivated/hepatitis B,
Glumetza (metformin extended-release) – PA;          recombinant vaccine – see Table 32, p. 114
   see Table 26, p. 101                            hepatitis B immune globulin, human – see
glyburide ° – see Table 26, p. 101                   Table 1, p. 39
glyburide/metformin – PA; see Table 26, p. 101     hepatitis B, recombinant vaccine – see
glyburide, micronized – see Table 26, p. 101         Table 32, p. 114
glycerin                                           Hepsera (adefovir) – PA > 30 units/month; see
glycopyrrolate                                       Table 44, p. 135
Glynase # (glyburide) – see Table 26, p. 101       Herceptin (trastuzumab)
Glyset (miglitol) – PA; see Table 26, p. 101       herpes zoster vaccine – PA < 60 years; see
gold sodium thiomalate                               Table 32, p. 114
golimumab – PA; see Table 5, p. 48                 hexachlorophene
GoLYTELY # (polyethylene glycol-electrolyte        HibTITER (haemophilus b conjugate vaccine) – see
   solution)                                         Table 32, p. 114
goserelin – PA; see Table 2, p. 41                 Hiprex (methenamine)
granisetron liquid formulation, tablet – PA; see   histrelin – PA
   Table 27, p. 103                                homatropine
granisetron injection – see Table 27, p. 103       Humalog (insulin lispro) prefilled syringe – PA; see
granisetron transdermal system – PA; see             Table 45, p. 137
   Table 27, p. 103                                Humalog (insulin lispro) vial – see Table 45, p. 137


May 3, 2010                                        15
Alphabetic List (cont.)

Humalog 50/50 (insulin lispro) prefilled syringe –   hydroxyzine – see Table 12, p. 64
  PA; see Table 45, p. 137                           hyoscyamine
Humalog 50/50 (insulin lispro) vial – see            hyoscyamine/phenobarbital
  Table 45, p. 137                                   Hyosol/SL (hyoscyamine, sublingual)
Humalog 75/25 (insulin lispro) prefilled syringe –   Hyospaz (hyoscyamine)
  PA; see Table 45, p. 137                           HyperHep (hepatitis B immune globulin, human) – see
Humalog 75/25 (insulin lispro) vial – see              Table 1, p. 39
  Table 45, p. 137                                   Hyper RAB (rabies immune globulin IM, human) – see
human papillomavirus bivalent vaccine – PA             Table 1, p. 39
  females < 10 years and > 25 years; see             Hypertet (tetanus immune globulin IM, human) – see
  Table 32, p. 114                                     Table 1, p. 39
human papillomavirus quadrivalent vaccine –          HypRho-D (Rho(D) immune globulin IM) – see
  PA < 9 years and > 26 years; see Table 32,           Table 1, p. 39
  p. 114                                             HypRho-D Mini-Dose (Rho(D) immune globulin IM
Humate-P (antihemophilic factor, human)                micro-dose) – see Table 1, p. 39
Humatrope (somatropin) – PA; see Table 9,            Hytakerol (dihydrotachysterol)
  p. 56                                              Hytone # (hydrocortisone) – see Table 16, p. 74
Humira (adalimumab) – PA; see Table 5, p. 48         Hytrin # (terazosin) – see Table 19, p. 84
Humulin 70/30 (NPH insulin/regular insulin)          Hyzaar (losartan/hydrochlorothiazide) – PA; see
  prefilled syringe – PA; see Table 45, p. 137         Table 18, p. 81
Humulin 70/30 (NPH insulin/regular insulin) vial
  – see Table 45, p. 137                             I
Humulin N (NPH insulin) prefilled syringe – PA;      Ibudone (hydrocodone/ibuprofen) – PA
  see Table 45, p. 137                               ibandronate – PA
Humulin N (NPH insulin) vial – see Table 45,         ibandronate IV – PA
  p. 137                                             ibritumomab – PA
Humulin R (regular insulin) vial – see Table 45,     ibuprofen * – see Table 11, p. 61
  p. 137                                             ibuprofen injection H – see Table 11, p. 61
Hycamtin (topotecan)                                 ibuprofen lysine H
Hycet (hydrocodone/acetaminophen) – PA; see          idursulfase – PA
  Table 8, p. 55                                     Ilaris (canakinumab) – PA
hydralazine                                          iloperidone – PA; see Table 24, p. 97
hydralazine/hydrochlorothiazide                      iloprost – see Table 43, p. 133
Hydra-zide # (hydralazine/hydrochlorothiazide)       imatinib
Hydrea # (hydroxyurea)                               Imdur # (isosorbide)
Hydrocet # (hydrocodone/acetaminophen) – see         imiglucerase – PA (effective 5/17/10)
  Table 8, p. 55                                     imipenem/cilastatin
hydrochlorothiazide                                  imipramine – see Table 17, p. 77
hydrocodone/acetaminophen ° – see Table 8,           imiquimod – PA
  p. 55                                              Imitrex (sumatriptan), injection – PA; see Table 14,
hydrocodone/ibuprofen ° – see Table 8, p. 55            p. 69
hydrocodone powder – PA; see Table 8, p. 55          Imitrex (sumatriptan), nasal spray – PA; see
hydrocortisone                                          Table 14, p. 69
hydrocortisone/aloe vera ° – see Table 16, p. 74     Imitrex # (sumatriptan), tablet – PA > 9 units/month;
hydrocortisone/lidocaine – PA; see Table 16,            see Table 14, p. 69
  p. 74                                              immune globulin IV, human – PA; see Table 1, p. 39
hydrocortisone, topical ° – see Table 16, p. 74      immune globulin, subcutaneous – PA; see
hydrocortisone/urea                                     Table 1, p. 39
hydrogen peroxide *                                  Imogam Rabies-HT (rabies immune globulin IM,
hydromorphone – PA > 60 mg/day; see Table 8,            human) – see Table 1, p. 39
  p. 55                                              Imovax (rabies vaccine) – see Table 32, p. 114
hydromorphone powder – PA; see Table 8,              Implanon (etonogestrel implant)
  p. 55                                              Imuran # (azathioprine)
hydrophilic ointment                                 Infanrix (diphtheria/tetanus toxoids/acellular pertussis
hydroxychloroquine                                      vaccine) – see Table 32, p. 114
hydroxycobalamin                                     Inapsine # (droperidol)
hydroxyprogesterone                                  Increlex (mecasermin) – PA
hydroxyurea                                          indapamide


May 3, 2010                                          16
Alphabetic List (cont.)

Inderal # (propranolol) – see Table 21, p. 91       Invega Sustenna (paliperidone injection) – PA > 2
Inderide # (propranolol/hydrochlorothiazide) –         units/month within the first 30 days of therapy;
  see Table 21, p. 91                                  PA > 1 unit/month after 30 days of therapy; see
indinavir – see Table 38, p. 125                       Table 24, p. 97
Indocin # (indomethacin) – see Table 11, p. 61      Invirase (saquinavir) – see Table 38, p. 125
indomethacin ° – see Table 11, p. 61                iodine *
Infed (iron dextran)                                Iopidine # (apraclonidine)
Infergen (interferon alfacon-1) – see Table 44,     IPOL (poliovirus vaccine, inactivated) – see
  p. 135                                               Table 32, p. 114
Inflamase # (prednisolone/sodium phosphate)         ipratropium, inhalation solution – see Table 23, p. 95
infliximab – PA; see Table 5, p. 48                 ipratropium, inhaler – see Table 23, p. 95
Influenza H1N1 Vaccine (influenza virus             ipratropium, nasal spray
  vaccine, H1N1) – see Table 32, p. 114             Iquix (levofloxacin, ophthalmic) – PA; see
influenza virus vaccine – see Table 32, p. 114         Table 34, p. 117
influenza virus vaccine, high dose – PA < 65        irbesartan – PA; see Table 18, p. 81
  years; see Table 32, p. 114                       irbesartan/hydrochlorothiazide – PA; see
influenza virus vaccine, H1N1 – see Table 32,          Table 18, p. 81
  p. 114                                            Iressa (gefitinib)
influenza virus vaccine live, intranasal – PA > 1   irinotecan
  dose/season; see Table 32, p. 114                 iron dextran
Infumorph (morphine) – see Table 8, p. 55           iron sucrose
InnoPran XL (propranolol extended-release) –        Isentress (raltegravir) – see Table 38, p. 125
  PA; see Table 21, p. 91                           Ismo # (isosorbide)
Inova (benzoyl peroxide) – PA; see Table 10,        isoetharine – see Table 23, p. 95
  p. 58                                             isoniazid
Inspra (eplerenone) – PA; see Table 33, p. 116      isopropyl alcohol *
insulin aspart, prefilled syringe – PA; see         Isoptin # (verapamil) – see Table 22, p. 93
  Table 45, p. 137                                  Isordil # (isosorbide)
insulin aspart, vial – see Table 45, p. 137         isosorbide
insulin detemir, prefilled syringe – PA; see        isosorbide dinitrate/hydralazine – PA
  Table 45, p. 137                                  isotretinoin – PA > 21 years; see Table 10, p. 58
insulin detemir, vial – see Table 45, p. 137        isradipine – see Table 22, p. 93
insulin glargine, prefilled syringe – PA; see       isradipine extended-release – PA; see Table 22, p. 92
  Table 45, p. 137                                  Istalol (timolol)
insulin glargine, vial – see Table 45, p. 137       itraconazole – see Table 47, p. 141
insulin glulisine, prefilled syringe – PA; see      Iveegam EN (immune globulin IV, human) – PA; see
  Table 45, p. 137                                     Table 1, p. 39
insulin glulisine, vial – see Table 45, p. 137      ivermectin
insulin lispro, prefilled syringe – PA; see         ixabepilone
  Table 45, p. 137                                  Ixempra (ixabepilone)
insulin lispro, vial – see Table 45, p. 137         Ixiaro (Japanese encephalitis vaccine) – see
Intelence (etravirine) – see Table 38, p. 125          Table 32, p. 114
interferon alfa-2b – see Table 44, p. 135
interferon alfa-2b/ribavirin – PA; see Table 44,    J
  p. 135
                                                    Janumet (sitagliptin/metformin) – PA; see
interferon alfacon-1 – see Table 44, p. 135
                                                      Table 26, p. 101
interferon alfa-n3, human leukocyte derived –
                                                    Januvia (sitagliptin) – PA – see Table 26, p. 101
  see Table 44, p. 135
                                                    Japanese encephalitis virus vaccine – see
interferon beta-1a – see Table 44, p. 135
                                                      Table 32, p. 114
interferon beta-1b – see Table 44, p. 135
                                                    Jenest-28 (ethinyl estradiol/norethindrone)
interferon gamma-1b – see Table 44, p. 135
                                                    JE-Vax (Japanese encephalitis virus vaccine) – see
Intron A (interferon alfa-2b) – see Table 44,
                                                      Table 32, p. 114
  p. 135
Intuniv (guanfacine extended-release) – PA; see     K
  Table 31, p. 111
Invanz (ertapenem)                                  Kadian (morphine sustained release) – PA; see Table
Invega (paliperidone) tablet – PA; see Table 24,     8, p. 55
  p. 97                                             Kaletra (lopinavir/ritonavir) – see Table 38, p. 125
                                                    Kaochlor (potassium chloride)

May 3, 2010                                         17
Alphabetic List (cont.)

kaolin/pectin *                                       Kytril # (granisetron) injection – see Table 27, p. 103
Kaon-Cl (potassium chloride)
Kariva (ethinyl estradiol/desogestrel)                L
Kayexalate # (sodium polystyrene sulfonate)           labetalol – see Table 21, p. 91
K-Dur # (potassium chloride)                          Lac-Hydrin (ammonium lactate) – PA
Keflex # (cephalexin) – see Table 35, p. 118          LAClotion (ammonium lactate) – PA
Keflex (cephalexin) 750 mg – PA; see Table 35,        lacosamide ° – see Table 20, p. 86
  p. 118                                              lactic acid #
Keftab (cephalexin)                                   lactic acid/vitamin E
Kenalog # (triamcinolone) – see Table 16, p. 74       Lactinol (lactic acid)
Kepivance (palifermin)                                Lactinol-E (lactic acid/vitamin E)
Keppra # (levetiracetam) – see Table 20, p. 86        lactose
Keppra XR (levetiracetam extended-release) –
                                                      lactulose °
  PA; see Table 20, p. 86
                                                      Lamictal # (lamotrigine) – see Table 20, p. 86
Kerlone # (betaxolol) – see Table 21, p. 91
                                                      Lamictal ODT (lamotrigine, orally disintegrating tablet)
ketamine – PA
                                                        – PA; see Table 20, p. 86
Ketek (telithromycin) – PA; see Table 35,
                                                      Lamictal ODT Start Kit (lamotrigine, orally
  p. 118
                                                        disintegrating tablet) – PA; see Table 20, p. 86
ketoconazole ° – see Table 28, p. 105; see
                                                      Lamictal Starter Kit (lamotrigine) – PA; see Table 20,
  Table 47, p. 141
                                                        p. 86
ketoprofen ° – see Table 11, p. 61
                                                      Lamictal XR (lamotrigine extended-release) – PA; see
ketorolac – PA > 20 units/month; see Table 11,
                                                        Table 20, p. 86
  p. 61
                                                      Lamictal XR Start Kit (lamotrigine extended-release) –
ketorolac ophthalmic solution °
                                                        PA; see Table 20, p. 86
Kineret (anakinra) – PA; see Table 5, p. 48
                                                      Lamisil # (terbinafine), tablet – see Table 47, p. 141
Kinrix (diphtheria/tetanus toxoids/acellular
                                                      Lamisil (terbinafine) granules – PA; see Table 47,
  pertussis/poliovirus, inactivated vaccine) – see
                                                        p. 141
  Table 32, p. 114
                                                      Lamisil (terbinafine), topical – PA; see Table 28,
Kionex # (sodium polystyrene sulfonate)
                                                        p. 105
Klaron # (sulfacetamide) – PA > 21 years; see
                                                      lamivudine ° – see Table 38, p. 125; see Table 44,
  Table 10, p. 58
                                                        p. 135
Klonopin # (clonazepam) – see Table 20, p. 86
                                                      lamivudine/zidovudine – see Table 38, p. 125
Klonopin Wafers (clonazepam, orally
                                                      lamotrigine ° – see Table 20, p. 86
  disintegrating tablets) – PA; see Table 20,
                                                      lamotrigine extended-release – PA; see Table 20,
  p. 86
                                                        p. 86
K-Lor # (potassium chloride)
                                                      lanolin *
Klor-Con # (potassium chloride)
                                                      Lanoxicaps (digoxin)
Klotrix (potassium chloride)
                                                      Lanoxin # (digoxin)
K-Lyte (potassium bicarbonate)
                                                      lanreotide
K-Lyte/Cl # (potassium chloride/potassium
                                                      lansoprazole capsule – PA > 2 years; see
  bicarbonate)
                                                        Table 3, p. 43
Koate-DVI (antihemophilic factor, human)
                                                      lansoprazole IV – PA; see Table 3, p. 43
Kogenate (antihemophilic factor, recombinant)
                                                      lansoprazole, orally disintegrating tablet –
Konyne 80 (factor IX complex)
                                                        PA > 2 years; see Table 3, p. 43
K-Phos M.F. (potassium phosphate/sodium
                                                      lansoprazole/amoxicillin/clarithromycin – PA; see
  phosphate)
                                                        Table 3, p. 43
K-Phos Neutral (potassium phosphate/dibasic
                                                      lanthanum
  sodium phosphate/monobasic sodium
                                                      Lantus (insulin glargine) prefilled syringe – PA; see
  phosphate)
                                                        Table 45, p. 137
K-Phos No. 2 (potassium phosphate/sodium
                                                      Lantus (insulin glargine) vial – see Table 45, p. 137
  phosphate/phosphorus)
                                                      lapatinib
K-Phos Original (potassium phosphate)
                                                      Lariam (mefloquine)
Kristalose (lactulose) – PA (effective 5/17/10)
                                                      laronidase – PA
K-Tab (potassium chloride)
                                                      Lasix # (furosemide)
Kuvan (sapropterin)
                                                      latanoprost – PA
K-Vescent Potassium Chloride (potassium
                                                      Lazer Formalyde (formaldehyde)
  chloride)
                                                      L-Carnitine (levocarnitine)
Kytril # (granisetron) liquid formulation, tablet –
                                                      leflunomide
  PA; see Table 27, p. 103

May 3, 2010                                           18
Alphabetic List (cont.)

lenalidomide                                        lidocaine/prilocaine – PA > 1 tube/month and
lepirudin – PA                                         PA > 3 months
Lescol (fluvastatin) – PA; see Table 13, p. 66      lidocaine/tetracaine – PA > 4 patches/month
Lescol XL (fluvastatin extended-release) – PA;      Lidoderm (lidocaine) – PA
   see Table 13, p. 66                              lindane – PA
Lessina (ethinyl estradiol/levonorgestrel)          linezolid, injection
Letairis (ambrisentan) – see Table 43, p. 133       linezolid, suspension – PA; see Table 35, p. 118
letrozole                                           linezolid, tablet – PA; see Table 35, p. 118
leucovorin                                          Lioresal # (baclofen) – see Table 7, p. 53
Leukeran (chlorambucil)                             Lioresal Intrathecal (baclofen) – see Table 7, p. 53
Leukine (sargramostim) – see Table 4, p. 46         liothyronine
leuprolide – PA; see Table 2, p. 41                 liothyronine/thyroxine
levalbuterol – PA; see Table 23, p. 95              Liotrix (liothyronine/thyroxine)
Levaquin (levofloxacin) – see Table 35, p. 118      Lipitor (atorvastatin) – PA; see Table 13, p. 66
Levatol (penbutolol) – PA; see Table 21, p. 91      Lipofen (fenofibrate) – PA; see Table 13, p. 66
Levbid (hyoscyamine)                                Liposyn # (fat emulsion, intravenous)
Levemir (insulin detemir) prefilled syringe – PA;   Lipram (amylase/lipase/protease)
   see Table 45, p. 137                             Liquicet (hydrocodone/acetaminophen) – PA; see
Levemir (insulin detemir) vial – see Table 45,         Table 8, p. 55
   p. 137                                           liraglutide – PA; see Table 45, p. 137
levetiracetam – see Table 20, p. 86                 lisdexamfetamine – PA; see Table 31, p. 111
levetiracetam extended-release – PA; see            lisinopril – see Table 18, p. 81
   Table 20, p. 86                                  lisinopril/hydrochlorothiazide – see Table 18, p. 81
Levlen # (ethinyl estradiol/levonorgestrel)         lithium
Levlite # (ethinyl estradiol/levonorgestrel)        Lithobid # (lithium)
Levo-Dromoran # (levorphanol) – PA > 32             Lithostat (acetohydroxamic acid)
   mg/day; see Table 8, p. 55                       L-methylfolate – PA
levocarnitine                                       Lo/Ovral # (ethinyl estradiol/norgestrel)
levobunolol                                         Locoid # (hydrocortisone) – see Table 16, p. 74
levocetirizine – PA; see Table 12, p. 64            lodoxamide – PA; see Table 29, p. 107
levofloxacin – see Table 35, p. 118                 Lodine # (etodolac) – see Table 11, p. 61
levofloxacin, ophthalmic – PA; see Table 34,        Lodosyn (carbidopa)
   p. 117                                           Loestrin # (ethinyl estradiol/norethindrone)
levoleucovorin – PA                                 Lofibra # (fenofibrate) – see Table 13, p. 66
levonorgestrel                                      Lomotil # (diphenoxylate/atropine)
levonorgestrel IUD                                  lomustine
Levora # (ethinyl estradiol/levonorgestrel)         Lonox # (diphenoxylate/atropine)
levorphanol – PA > 32 mg/day; see Table 8,          loperamide *
   p. 55                                            Lopid # (gemfibrozil) – see Table 13, p. 66
levorphanol powder – PA; see Table 8, p. 55         lopinavir/ritonavir – see Table 38, p. 125
Levothroid # (levothyroxine)                        Lopressor # (metoprolol) – see Table 21, p. 91
levothyroxine                                       Lopressor HCT # (metoprolol/hydrochlorothiazide) –
Levoxyl # (levothyroxine)                              see Table 21, p. 91
Levsin (hyoscyamine)                                Loprox ° (ciclopirox) – see Table 28, p. 105
Levsin PB (hyoscyamine/phenobarbital)               loratadine – see Table 12, p. 64
Levsinex Timecaps # (hyoscyamine)                   lorazepam – see Table 20, p. 86
Lexapro (escitalopram) – PA; see Table 17,          lorazepam powder – PA; see Table 20, p. 86
   p. 77                                            Lorcet # (hydrocodone/acetaminophen) – see
Lexiva (fosamprenavir) – see Table 38, p. 125          Table 8, p. 55
L-glutamine – PA                                    Lortab # (hydrocodone/acetaminophen) – see
Lialda (mesalamine) – PA                               Table 8, p. 55
Librium # (chlordiazepoxide)                        losartan – PA; see Table 18, p. 81
LidaMantle (lidocaine) – PA                         losartan/hydrochlorothiazide – PA; see Table 18, p. 81
LidaMantle HC (hydrocortisone/lidocaine) – PA;      LoSeasonique (ethinyl estradiol/levonorgestrel)
   see Table 16, p. 74                              Lotemax (loteprednol)
Lidex # (fluocinonide) – see Table 16, p. 74        Lotensin # (benazepril); see Table 18, p. 81
lidocaine ° – see Table 16, p. 74                   Lotensin HCT # (benazepril/hydrochlorothiazide) – see
lidocaine ophthalmic gel                               Table 18, p. 81
lidocaine patch – PA

May 3, 2010                                         19
Alphabetic List (cont.)

loteprednol ° – see Table 29, p. 107               Marcaine # (bupivacaine)
loteprednol/tobramycin – see Table 34, p. 117      Marinol (dronabinol) – PA
Lotrel (amlodipine/benazepril) – PA; see           Marten-tab # (butalbital/acetaminophen)
  Table 18, p. 81; see Table 22, p. 93             Matulane (procarbazine)
Lotrimin # (clotrimazole) – see Table 28, p. 105   Mavik # (trandolapril) – see Table 18, p. 81
Lotrisone # (clotrimazole/betamethasone) – see     Maxair (pirbuterol) – PA; see Table 23, p. 95
  Table 28, p. 105                                 Maxalt (rizatriptan) – PA; see Table 14, p. 69
Lotronex (alosetron) – PA                          Maxalt-MLT (rizatriptan, orally disintegrating tablet) –
lovastatin – PA > 30 units/month; see Table 13,     PA; see Table 14, p. 69
  p. 66                                            Maxidex (dexamethasone)
lovastatin extended-release – PA; see              Maxidone # (hydrocodone/acetaminophen) – see
  Table 13, p. 66                                   Table 8, p. 55
lovastatin/niacin extended-release – PA; see       Maxipime # (cefepime)
  Table 13, p. 66                                  Maxitrol # (neomycin/polymyxin B/
Lovaza (omega-3-acid ethyl ester) – PA; see         dexamethasone) – see Table 34, p. 117
  Table 13, p. 66                                  Maxzide # (triamterene/hydrochlorothiazide)
Lovenox (enoxaparin)                               measles/mumps/rubella vaccine – see Table 32,
Low-Ogestrel # (ethinyl estradiol/norgestrel)       p. 114
loxapine                                           measles/mumps/rubella/varicella virus vaccine – see
Loxitane # (loxapine)                               Table 32, p. 114
Lozol # (indapamide)                               measles virus vaccine, live – see Table 32, p. 114
lubiprostone – PA                                  Mebaral (mephobarbital)
Lucentis (ranibizumab) ^                           mebendazole
Lufyllin-GG (dyphylline/guaifenesin)               mecasermin – PA
Lumigan (bimatoprost) – PA                         mechlorethamine
Lunelle (estradiol/medroxyprogesterone)            meclizine *
Lunesta (eszopiclone) – PA; see Table 15, p. 72    meclofenamate – see Table 11, p. 61
Lupron (leuprolide) – PA; see Table 2, p. 41       Medrol # (methylprednisolone)
Luride # (sodium fluoride)                         medroxyprogesterone
Luvox # (fluvoxamine) – see Table 17, p. 77        medroxyprogesterone/estrogen conjugated
Luvox CR (fluvoxamine extended-release) – PA;      mefenamic acid – PA; see Table 11, p. 61
  see Table 17, p. 77                              mefloquine
Luxiq (betamethasone) – PA; see Table 16,          Mefoxin # (cefoxitin)
  p. 74                                            Megace # (megestrol)
Lybrel (ethinyl estradiol/levonorgestrel)          Megace ES (megestrol, oral suspension) – PA
Lynox (oxycodone/acetaminophen) – PA; see          megestrol °
  Table 8, p. 55                                   Mellaril # (thioridazine)
Lyrica (pregabalin) – PA; see Table 20, p. 86      meloxicam ° – see Table 11, p. 61
                                                   melphalan
M                                                  memantine
                                                   Menactra (meningococcal conjugate vaccine) – see
Macrobid # (nitrofurantoin) – see Table 35,
                                                    Table 32, p. 114
 p. 118
                                                   Menest (estrogens, esterified)
Macrodantin # (nitrofurantoin) – see Table 35,
                                                   meningococcal conjugate vaccine – see Table 32,
 p. 118
                                                    p. 114
Macugen (pegaptanib) ^
                                                   meningococcal polysaccharide vaccine – see
mafenide
                                                    Table 32, p. 114
magaldrate *
                                                   meningococcal quadrivalent vaccine – see
Magnacet (oxycodone/acetaminophen) – PA;
                                                    Table 32, p. 114
 see Table 8, p. 55
                                                   Menomune-A/C/Y/W-135 (meningococcal
magnesium citrate *
                                                    polysaccharide vaccine) – see Table 32, p. 114
magnesium gluconate *
                                                   Menostar (estradiol)
magnesium hydroxide *
                                                   Mentax (butenafine) – PA; see Table 28, p. 105
magnesium trisalicylate *
                                                   Menveo–A/C/Y/W-135 (meningococcal quadrivalent
Malarone (atovaquone/proguanil)
                                                    vaccine) – see Table 32, p. 114
malathion
                                                   mepenzolate
Mandelamine (methenamine)
                                                   meperidine – PA; see Table 8, p. 55
maprotiline – see Table 17, p. 77
                                                   mephobarbital
maraviroc – PA; see Table 38, p. 125
                                                   Mephyton (phytonadione)

May 3, 2010                                        20
Alphabetic List (cont.)

meprobamate                                    Methylin (methylphenidate) – PA > 90 units/month;
meprobamate/aspirin                             see Table 31, p. 111
Mepron (atovaquone)                            Methylin (methylphenidate) oral solution – PA > 900
mercaptopurine                                  ml/month; see Table 31, p. 111
meropenem                                      methylnaltrexone – PA
Merrem (meropenem)                             methylphenidate – PA > 90 units/month; see
Meruvax II (rubella virus vaccine) – see        Table 31, p. 111
 Table 32, p. 114                              methylphenidate extended-release ° – see Table 31,
mesalamine °                                    p. 111
mesna                                          methylphenidate oral solution – PA > 900 ml/month;
Mesnex (mesna)                                  see Table 31, p. 111
mesoridazine                                   methylphenidate powder – PA; see Table 31, p. 111
Mestinon # (pyridostigmine)                    methylphenidate transdermal system – PA; see
Metadate CD (methylphenidate extended-          Table 31, p. 111
 release) – PA > 60 units/month; see           methylprednisolone
 Table 31, p. 111                              methyltestosterone
Metadate ER # (methylphenidate extended-       methysergide
 release) – PA > 90 units/month; see           metipranolol
 Table 31, p. 111                              metoclopramide
Metaglip (metformin/glipizide) – PA; see       metoclopramide, orally disintegrating tablet – PA
 Table 26, p. 101                              metolazone
metaproterenol, inhalation solution – see      metoprolol – see Table 21, p. 91
 Table 23, p. 95                               metoprolol/hydrochlorothiazide – see Table 21, p. 91
metaproterenol, inhaler – PA; see Table 23,    MetroCream # (metronidazole) – see Table 10, p. 58
 p. 95                                         Metrogel (metronidazole) – PA; see Table 10, p. 58
metaxalone – PA; see Table 7, p. 53            MetroLotion # (metronidazole) – see Table 10, p. 58
metformin – see Table 26, p. 101               metronidazole ° – see Table 35, p. 118
metformin extended-release ° – see Table 26,   metronidazole extended-release – PA; see
 p. 101                                         Table 35, p. 118
metformin solution – see Table 26, p. 101      metronidazole °, topical – see Table 10, p. 58
metformin/repaglinide – PA; see Table 26,      Metozolv ODT (metoclopramide, orally disintegrating
 p. 101                                         tablet) – PA
metformin/rosiglitazone – PA; see Table 26,    metyrosine
 p. 101                                        Mevacor # (lovastatin) – PA > 30 units/month; see
methadone – PA > 120 mg/day; see Table 8,       Table 13, p. 66
 p. 55                                         mexiletine
methadone powder – PA; see Table 8, p. 55      Mexitil # (mexiletine)
Methadose (methadone) – PA > 120 mg/day;       micafungin
 see Table 8, p. 55                            Miacalcin # (calcitonin, salmon)
methamphetamine – PA                           Micanol (anthralin)
methazolamide                                  Micardis (telmisartan) – PA; see Table 18, p. 81
methenamine                                    Micardis HCT (telmisartan/hydrochlorothiazide) – PA;
methenamine/benzoic acid/atropine/              see Table 18, p. 81
 hyoscyamine/saldol/methylene blue             miconazole ° – see Table 28, p. 105
methenamine/hyoscyamine/methylene blue         miconazole/zinc oxide – PA
methenamine/sodium acid phosphate              MICRhoGAM (Rho(D) immune globulin IM micro-dose)
Methergine (methylergonovine)                   – see Table 1, p. 39
methimazole                                    Microgestin Fe # (ethinyl estradiol/
Methitest (methyltestosterone)                  norethindrone)
methocarbamol – see Table 7, p. 53             Micro-K # (potassium chloride)
methotrexate                                   Micronase # (glyburide) – see Table 26, p. 101
methoxsalen                                    Micronor # (norethindrone)
methscopolamine                                Microzide # (hydrochlorothiazide)
methsuximide – see Table 20, p. 86             Midamor # (amiloride)
methyclothiazide                               midazolam
methyclothiazide/deserpidine                   midodrine
methyldopa                                     miglitol – PA; see Table 26, p. 101
methyldopa/hydrochlorothiazide                 miglustat
methylergonovine                               Migranal (dihydroergotamine) – PA

May 3, 2010                                    21
Alphabetic List (cont.)

Millipred (prednisolone) – PA                      morphine extended-release – PA; see Table 8, p. 55
milnacipran – PA                                   morphine immediate release – PA > 360 mg/day; see
milrinone                                           Table 8, p. 55
mineral oil *                                      morphine injection – see Table 8, p. 55
Mini-Gamulin Rh (Rho(D) immune globulin IM         morphine powder – PA
 micro-dose) – see Table 1, p. 39                  morphine sustained release – PA; see Table 8, p. 55
Minitran # (nitroglycerin)                         morphine suppositories – see Table 8, p. 55
Minizide (prazosin/polythiazide) – see Table 19,   morphine/naloxone – PA; see Table 8, p. 55
 p. 84                                             Motofen (atropine/difenoxin)
Minocin # (minocycline) – see Table 35, p. 118     Motrin # (ibuprofen *) – see Table 11, p. 61
minocycline – see Table 10, p. 58; see Table 35,   MoviPrep (polyethylene glycol/electrolyte solution) –
 p. 118                                             PA
minocycline extended release – PA; see             Moxatag (amoxicillin, extended-release) – PA; see
 Table 10, p. 58; see Table 35, p. 118              Table 35, p. 118
minoxidil                                          moxifloxacin – see Table 35, p. 118
Mintezol (thiabendazole)                           moxifloxacin, ophthalmic – PA; see Table 34, p. 117
Miralax # (polyethylene glycol)                    Mozobil (plerixafor)
Mirapex (pramipexole)                              MSIR (morphine) – PA > 360 mg/day; see Table 8,
Mircette # (ethinyl estradiol/desogestrel)          p. 55
Mirena (levonorgestrel IUD)                        MS/L (morphine) – PA > 360 mg/day; see
mirtazapine – see Table 17, p. 77                   Table 8, p. 55
mirtazapine, orally disintegrating tablet – PA;    MS Contin # (morphine) – PA > 360 mg/day; see
 see Table 17, p. 77                                Table 8, p. 55
misoprostol                                        MS/S (morphine) – see Table 8, p. 55
mitomycin                                          Mucomyst # (acetylcysteine)
mitoxantrone                                       Mucomyst-10 (acetylcysteine)
M-M-R II (measles/mumps/rubella vaccine) –         Multaq (dronedarone)
 see Table 32, p. 114                              multivitamins *
Moban (molindrone)                                 multivitamins/minerals *
Mobic # (meloxicam) – PA < 60 years; see           Mumpsvax (mumps virus vaccine) – see Table 32,
 Table 11, p. 61                                    p. 114
modafinil – PA                                     mumps virus vaccine – see Table 32, p. 114
Modicon # (ethinyl estradiol/norethindrone)        mupirocin ° – see Table 41, p. 131
Moduretic # (amiloride/hydrochlorothiazide)        Murocoll-2 (scopolamine/phenylephrine)
moexipril – see Table 18, p. 81                    Mustargen (mechlorethamine)
moexipril/hydrochlorothiazide – see Table 18,      Myambutol # (ethambutol)
 p. 81                                             Mycamine (micafungin)
molindone                                          Mycelex Troche # – see Table 47, p. 141
mometasone, inhaler – see Table 23, p. 95          Mycobutin (rifabutin)
mometasone, topical – see Table 16, p. 74          mycophenolate
mometasone, nasal spray –PA > 4 years and          Mycostatin # (nystatin) – see Table 28, p. 105; see
 > 1 inhaler/month; see Table 25, p. 99             Table 47, p. 141
Monarc-M (antihemophilic factor, human)            Mydfrin (phenylephrine)
Monistat-Derm (miconazole) – PA; see               Mydriacyl # (tropicamide)
 Table 28, p. 105                                  Myfortic (mycophenolate)
Monoclate-P (antihemophilic factor, human)         Mylotarg (gemtuzumab)
Monodox # (doxycycline) – see Table 35, p. 118     Myobloc (rimabotulinumtoxin B) – PA; see
Monodox 75mg (doxycycline) – PA; see                Table 30, p. 109
 see Table 35, p. 118                              Myozyme (alglucosidase) – PA
Monoket # (isosorbide)                             Mysoline # (primidone) – see Table 20, p. 86
Mononine (factor IX, human)
Monopril # (fosinopril) – see Table 18, p. 81      N
Monopril HCT # (fosinopril/ hydrochlorothiazide)   Nabi-HB (hepatitis B immune globulin, human) – see
 – see Table 18, p. 81                               Table 1, p. 39
montelukast – PA > 16 years; PA                    nabilone – PA
 (effective 5/17/10); see Table 40, p. 129         nabumetone – see Table 11, p. 61
Monurol (fosfomycin) – see Table 35, p. 118        nadolol – see Table 21, p. 91
morphine controlled release – PA > 360             nadolol/bendroflumethiazide – see Table 21, p. 91
 mg/day; see Table 8, p. 55

May 3, 2010                                        22
Alphabetic List (cont.)

nafarelin – PA; see Table 2, p. 41                nelfinavir – see Table 38, p. 125
nafcillin                                         Nelova # (ethinyl estradiol/norethindrone)
naftifine – PA; see Table 28, p. 105              Nembutal # (pentobarbital)
Naftin (naftifine) – PA; see Table 28, p. 105     NeoBenz Micro (benzoyl peroxide) – PA; see
Naglazyme (galsulfase) – PA                         Table 10, p. 58
nalbuphine                                        neomycin * – see Table 35, p. 118
Nalfon 200 mg, 400 mg (fenoprofen) – PA; see      neomycin/bacitracin/polymyxin B/hydrocortisone,
  Table 11, p. 61                                   ophthalmic – see Table 34, p. 117
nalidixic acid                                    neomycin/polymyxin B/dexamethasone – see
Nallpen (nafcillin)                                 Table 34, p. 117
naloxone – see Table 36, p. 120                   neomycin/polyxmyxin B/gramicidin
naltrexone                                        neomycin/polymyxin B/hydrocortisone – see
naltrexone injection – PA; see Table 36, p. 120     Table 34, p. 117
Namenda (memantine)                               neomycin/polymyxin B/prednisolone – see
nandrolone                                          Table 34, p. 117
                                                                                  H
naphazoline                                       NeoProfen (ibuprofen lysine)
naphazoline/pheniramine – see Table 29, p. 107    Neoral # (cyclosporine)
Naphcon-A (naphazoline/pheniramine) – see         Neosar # (cyclophosphamide)
  Table 29, p. 107                                Neosporin Ophthalmic Solution # (neomycin/polymyxin
Naprelan CR 375 mg, 500 mg (naproxen                B/gramicidin)
  controlled-release) – PA; see Table 11, p. 61   neostigmine
Naprelan CR 750 mg (naproxen controlled-          nepafenac – PA
  release) – PA; see Table 11, p. 61              Neptazane # (methazolamide)
Naprosyn # (naproxen *) – see Table 11, p. 61     nesiritide H
naproxen * – see Table 11, p. 61                  Neulasta (pegfilgrastim) – see Table 4, p. 46
naproxen controlled-release 375 mg, 500 mg –      Neumega (oprelvekin) – see Table 4, p. 46
  PA; see Table 11, p. 61                         Neupogen (filgrastim) – see Table 4, p. 46
naproxen controlled-release 750 mg – PA; see      Neurontin # (gabapentin) – see Table 20, p. 86
  Table 11, p. 61                                 Nevanac (nepafenac) – PA
naproxen extended-release – PA; see Table 11,     nevirapine – see Table 38, p. 125
  p. 61                                           Nexavar (sorafenib)
naproxen/lansoprazole – PA; see Table 11,         Nexium (esomeprazole) – PA; see Table 3, p. 43
  p. 61                                           Nexium IV (esomeprazole) – PA; see Table 3, p. 43
Naqua (trichlormethiazide)                        niacin * – see Table 13, p. 66
naratriptan – PA; see Table 14, p. 69             niacin extended-release/lovastatin – PA; see
Nardil (phenelzine) – see Table 17, p. 77           Table 13, p. 66
Nasacort AQ (triamcinolone nasal spray) –         niacin extended-release/simvastatin – PA; see
  PA > 4 years and 1 inhaler/month; see             Table 13, p. 66
  Table 25, p. 99                                 niacin, extended-release tablet – see Table 13,
Nasarel # (flunisolide nasal spray) – PA > 1        p. 66
  inhaler/month; see Table 25, p. 99              niacinamide * – see Table 13, p. 66
Nascobal (cyanocobalamin) – PA                    Niaspan (niacin, extended-release tablet) –
Nasonex (mometasone nasal spray) – PA > 4           see Table 13, p. 66
  years and > 1 inhaler/month; see Table 25,      nicardipine – see Table 22, p. 93
  p. 99                                           nicotine gum – PA > 90 days/treatment regimen and
natalizumab                                         PA > two treatment regimens/year; see Table 6,
nateglinide – PA; see Table 26, p. 101              p. 51
Natrecor H (nesiritide)                           nicotine inhaler – PA; see Table 6, p. 51
Navane # (thiothixene)                            nicotine lozenge – PA > 90 days/treatment regimen
Navelbine (vinorelbine)                             and PA > two treatment regimens/year; see
nebivolol – PA; – see Table 21, p. 91               Table 6, p. 51
Nebupent (pentamidine)                            nicotine nasal spray – PA; see Table 6, p. 51
Necon # (ethinyl estradiol/norethindrone)         nicotine transdermal patch (generics) – PA > 90
nedocromil, inhaler – see Table 23, p. 95           days/treatment regimen and PA > two treatment
nedocromil ophthalmic – PA; see Table 29,           regimens/year; see Table 6, p. 51
  p. 107                                          nicotinic acid * – see Table 13, p. 66
nefazodone – see Table 17, p. 77                  Nicotrol (nicotine), nasal spray – PA; see
NegGram # (nalidixic acid)                          Table 6, p. 51
nelarabine – PA                                   Nicotrol (nicotine), inhaler – PA; see Table 6, p. 51

May 3, 2010                                       23
Alphabetic List (cont.)

Nifedical (nifedipine) – see Table 22, p. 93         Novolin 70/30 (NPH insulin/regular insulin) vial – see
nifedipine – see Table 22, p. 93                       Table 45, p. 137
Nilandron (nilutamide)                               Novolin N (NPH insulin) prefilled syringe – PA; see
nilotinib                                              Table 45, p. 137
Nilstat # (nystatin) – see Table 47, p. 141          Novolin N (NPH insulin) vial – see Table 45, p. 137
nilutamide                                           Novolin R (regular insulin) prefilled syringe – PA; see
nimodipine – see Table 22, p. 93                       Table 45, p. 137
Niravam (alprazolam, orally disintegrating tablet)   Novolin R (regular insulin) vial – see Table 45, p. 137
   – PA                                              Novolog (insulin aspart) prefilled syringe – PA; see
nisoldipine – PA; see Table 22, p. 93                  Table 45, p. 137
nitazoxanide suspension – PA                         Novolog (insulin aspart) vial – see Table 45, p. 137
nitazoxanide tablet – PA                             Novolog 70/30 (insulin aspart) prefilled syringe – PA;
nitisinone                                             see Table 45, p. 137
Nitrek # (nitroglycerin)                             Novolog 70/30 (insulin aspart) vial – see Table 45,
Nitro-Bid # (nitroglycerin)                            p. 137
Nitrodisc (nitroglycerin)                            Novoseven (eptacog alfa)
Nitro-Dur # (nitroglycerin)                          Noxafil (posaconazole) – PA; see Table 47, p. 141
nitrofurantoin – see Table 35, p. 118                NPH insulin, prefilled syringe – PA; see Table 45,
nitrofurazone                                          p. 137
nitroglycerin                                        NPH insulin, vial – see Table 45, p. 137
Nitrol (nitroglycerin)                               NPH insulin/regular insulin, prefilled syringe – PA; see
Nitrolingual (nitroglycerin)                           Table 45, p. 137
Nitroquick (nitroglycerin)                           NPH insulin/regular insulin, vial – see Table 45, p. 137
Nitrostat # (nitroglycerin)                          Nplate (romiplostim) – PA
Nitrotab (nitroglycerin)                             Nucort (hydrocortisone/aloe vera) – PA; see Table 16,
Nitro-Time (nitroglycerin)                             p. 74
nizatidine – PA; see Table 3, p. 43                  Nucynta (tapentadol) – PA; see Table 8, p. 55
Nizoral # (ketoconazole) – see Table 28, p. 105;     Nulev (hyoscyamine)
   see Table 47, p. 141                              NuLytely # (polyethylene glycol-electrolyte solution)
nonoxynol-9 *                                        Numorphan (oxymorphone) – see Table 8, p. 55
Norco # (hydrocodone/acetaminophen) – see            NuOx (benzoyl peroxide/sulfur) – PA; see Table 10,
   Table 8, p. 55                                      p. 58
Nordette # (ethinyl estradiol/levonorgestrel)        NutreStore (L-glutamine) – PA
Norditropin (somatropin) – PA; see Table 9,          Nutropin (somatropin) – PA; see Table 9, p. 56
   p. 56                                             Nutropin AQ (somatropin) – PA; see Table 9, p. 56
norethindrone                                        NuvaRing (etonogestrel/ethinyl estradiol)
Norflex # (orphenadrine) – see Table 7, p. 53        Nuvigil (armodafanil) – PA
norfloxacin – see Table 35, p. 118                   Nuzon (hydrocortisone) – PA; see Table 16, p. 74
Norgesic # (orphenadrine/aspirin/caffeine) – see     nystatin – see Table 28, p. 105; see Table 47, p. 141
   Table 7, p. 53                                    nystatin/neomycin/triamcinolone/gramicidin
Norgestimate/ethinyl estradiol                       nystatin/triamcinolone – see Table 28, p. 105
norgestrel
Norinyl # (ethinyl estradiol/norethindrone)          O
Noritate (metronidazole) – PA; see Table 10,
                                                     octreotide
   p. 58
                                                     Ocufen # (flurbiprofen)
Normodyne # (labetalol) – see Table 21, p. 91
                                                     Ocuflox # (ofloxacin) – see Table 34, p. 117
Noroxin (norfloxacin) – see Table 35, p. 118
                                                     Ocupress # (carteolol)
Norpace # (disopyramide)
                                                     Ocusulf-10 # (sulfacetamide)
Norpramin # (desipramine) – see Table 17, p. 77
                                                     ofatumumab – PA
Nor-Q-D # (norethindrone)
                                                     ofloxacin – see Table 35, p. 118
Nortrel (ethinyl estradiol/norethindrone)
                                                     ofloxacin, otic solution °
nortriptyline – see Table 17, p. 77
                                                     ofloxacin, ophthalmic – see Table 34, p. 117
Norvasc # (amlodipine) – see Table 22, p. 93
                                                     Oforta (fludaribine)
Norvir (ritonavir) capsule – see Table 38, p. 125
                                                     Ogen # (estropipate)
Norvir (ritonavir) tablet – PA; see Table 38,
                                                     Ogestrel # (ethinyl estradiol/norgestrel)
   p. 125
                                                     olanzapine injection – see Table 24, p. 97
Novantrone # (mitoxantrone)
                                                     olanzapine, orally disintegrating tablets – PA; see
Novolin 70/30 (NPH insulin/regular insulin)
                                                       Table 24, p. 97
   prefilled syringe – PA; see Table 45, p. 137

May 3, 2010                                          24
Alphabetic List (cont.)

olanzapine pamoate 210 mg, 300 mg – PA > 2          Orapred ODT (prednisolone, orally disintegrating
  injections/month; see Table 24, p. 97               tablet) – PA
olanzapine pamoate 405 mg – PA > 1                  Orasone (prednisone)
  injection/month; see Table 24, p. 97              Ora-Sweet-SF syrup
olanzapine tablet – PA > 30 units/month; see        Ora-Sweet oral syrup
  Table 24, p. 97                                   Orencia (abatacept) – PA; see Table 5, p. 48
olanzapine/fluoxetine – PA; see Table 17, p. 77;    Oretic # (hydrochlorothiazide)
  see Table 24, p. 97                               Orfadin (nitisinone)
olmesartan – PA; see Table 18, p. 81                orphenadrine – see Table 7, p. 53
olmesartan/hydrochlorothiazide – PA; see            orphenadrine/aspirin/caffeine – see Table 7, p. 53
  Table 18, p. 81                                   Orphengesic # (orphenadrine/aspirin/caffeine) – see
olopatadine – PA; see Table 12, p. 64; see            Table 7, p. 53
  Table 29, p. 107                                  Ortho-Cept # (ethinyl estradiol/desogestrel)
olsalazine                                          Ortho-Cyclen # (ethinyl estradiol/norgestimate)
Olux (clobetasol) – PA; see Table 16, p. 74         Ortho-Est # (estropipate)
omalizumab – PA                                     Ortho-Evra (ethinyl estradiol/norelgestromin)
omega-3-acid ethyl ester – PA; see Table 13,        Ortho-Novum # (ethinyl estradiol/norethindrone)
  p. 66                                             Ortho-Prefest (estradiol/norgestimate)
omeprazole ° – see Table 3, p. 43                   OrthoTri-Cyclen # (ethinyl estradiol/norgestimate)
Omnaris AQ (ciclesonide nasal spray) – PA; see      OrthoTri-Cyclen Lo (ethinyl estradiol/norgestimate)
                                                                                                   st
  Table 25, p. 99                                   oseltamivir 30 mg – PA all quantities (June 1 to
                                                                      th
Omnicef # (cefdinir) – see Table 35, p. 118           September 30 ); PA > 20 capsules/month and
Omnipen # (ampicillin) – see Table 35, p. 118         PA > 40 capsules/season (October 1st to
Omnitrope (somatropin) – PA; see Table 9,             May 31st); see Table 39, p. 127
  p. 56                                             oseltamivir 45 mg and 75 mg – PA all quantities
OMS (morphine) – PA > 360 mg/day; see                 (June 1st to September 30 th); PA > 10
  Table 8, p. 55                                      capsules/month and PA > 20 capsules/season
onabotulinumtoxin A – PA; see Table 30, p. 109        (October 1st to May 31st); see Table 39, p. 127
ondansetron 4 mg, 8 mg – PA > 15                    oseltamivir suspension – PA all quantities (June 1st
  units/month; see Table 27, p. 103                   to September 30 th); PA > 75 ml/month and
ondansetron injection – see Table 27, p. 103          PA > 150 ml/season (October 1st to May 31st); see
ondansetron 24 mg – PA > 5 units/month; see           Table 39, p. 127
  Table 27, p. 103                                  Osmoglyn (glycerin)
ondansetron, orally disintegrating tablet – PA;     OsmoPrep (sodium phosphate) – PA
  see Table 27, p. 103                              Oticaine (benzocaine)
ondansetron solution – PA > 50 mL/month; see        Otocain (benzocaine)
  Table 27, p. 103                                  Ovcon (ethinyl estradiol/norethindrone)
Onglyza (saxagliptin) – PA; see Table 26, p. 101    Ovide (malathion)
Onsolis (fentanyl buccal film) – PA; see Table 8,   Ovral # (ethinyl estradiol/norgestrel)
  p. 55                                             Ovrette (norgestrel)
Onxol # (paclitaxel)                                oxacillin
Opana (oxymorphone) – PA; see Table 8, p. 55        oxaliplatin
Opana ER (oxymorphone extended release) –           Oxandrin (oxandrolone) – PA
  PA; see Table 8, p. 55                            oxandrolone – PA
Opcon-A (naphazoline/pheniramine) – see             oxaprozin – see Table 11, p. 61
  Table 29, p. 107                                  oxazepam
opium                                               oxcarbazepine – see Table 20, p. 86
oprelvekin – see Table 4, p. 46                     oxiconazole – PA; see Table 28, p. 105
Opticrom # (cromolyn)                               Oxistat (oxiconazole) – PA; see Table 28, p. 105
Optipranolol # (metipranolol)                       Oxsoralen (methoxsalen)
Optivar (azelastine) – PA; see Table 29, p. 107     Oxsoralen-Ultra (methoxsalen)
Oracea (doxycycline) – PA; see Table 10, p. 58;     oxybutynin – see Table 46, p. 139
  see Table 35, p. 118                              oxybutynin extended-release – see Table 46, p. 139
Oralone # (triamcinolone)                           oxybutynin gel – PA – see Table 46, p. 139
Oramorph SR (morphine) – PA > 360 mg/day;           oxybutynin transdermal system – PA; see
  see Table 8, p. 55                                  Table 46, p. 139
Orap (pimozide)                                     oxycodone powder – PA; see Table 8, p. 55
Ora-Plus suspending vehicle                         oxycodone controlled release – PA; see Table 8,
Orapred # (prednisolone)                              p. 55

May 3, 2010                                         25
Alphabetic List (cont.)

oxycodone immediate release – PA > 240              Parafon Forte DSC # (chlorzoxazone) – see Table 7,
  mg/day; see Table 8, p. 55                          p. 53
oxycodone/acetaminophen ° – see Table 8,            Paragard (copper IUD)
  p. 55                                             Paraplatin (carboplatin)
oxycodone/aspirin – see Table 8, p. 55              Parcopa (carbidopa/levodopa, orally disintegrating
oxycodone/ibuprofen – PA; see Table 8, p. 55          tablet) – PA
OxyContin (oxycodone controlled release) –          paregoric
  PA; see Table 8, p. 55                            paricalcitol
Oxydose (oxycodone) – PA > 240 mg/day; see          Parlodel # (bromocriptine)
  Table 8, p. 55                                    Parnate # (tranylcypromine) – see Table 17, p. 77
OxyFast (oxycodone) – PA > 240 mg/day; see          paromomycin – see Table 35, p. 118
  Table 8, p. 55                                    paroxetine ° – see Table 17, p. 77
Oxy IR (oxycodone) – PA > 240 mg/day; see           paroxetine controlled release – PA; see
  Table 8, p. 55                                      Table 17, p. 77
oxymetholone                                        Pataday (olopatadine) – PA; see Table 29, p. 107
oxymorphone extended release tablet – see           Patanase (olopatadine) – PA; see Table 12, p. 64
  Table 8, p. 55                                    Patanol (olopatadine) – PA; see Table 29, p. 107
oxymorphone injection – see Table 8, p. 55          Paxil # (paroxetine) – see Table 17, p. 77
oxymorphone suppository – see Table 8, p. 55        Paxil CR (paroxetine controlled release) – PA; see
oxymorphone tablet – see Table 8, p. 55               Table 17, p. 77
oxytetracycline/polymyxin B                         pazopanib
oxytocin                                            PCE Dispertab (erythromycin) – see Table 35, p. 118
Oxytrol (oxybutynin) transdermal system – PA;       Pediapred # (prednisolone)
  see Table 46, p. 139                              Pediarix (diphtheria/tetanus toxoids/acellular
Ozurdex (dexamethasone intravitreal implant) ^        pertussis/hepatitis B, recombinant/poliovirus,
                                                      inactivated vaccine) – see Table 32, p. 114
P                                                   pediatric multivitamins *
P2E1 (pilocarpine/epinephrine)                      Pedi-Dri (nystatin)
Pacerone # (amiodarone)                             Pediotic # (neomycin/polymyxin B/hydrocortisone)
paclitaxel                                          PedvaxHIB (haemophilus b conjugate vaccine) – see
Palgic (carbinoxamine) – PA; see Table 12,            Table 32, p. 114
  p. 64                                             Peganone (ethotoin) – see Table 20, p. 86
palifermin                                          pegaptanib ^
paliperidone tablet – PA for new starts only;       Pegasys (peginterfereon alfa-2a) – PA > 4
  see Table 24, p. 97                                 doses/month; PA (effective 5/17/10); see
paliperidone injection – PA > 2 units/month           Table 44, p. 135
  within the first 30 days of therapy; PA > 1       pegfilgrastim – see Table 4, p. 46
  unit/month after 30 days of therapy; see          peginterfereon alfa-2a – PA > 4 doses/month; PA
  Table 24, p. 97                                     (effective 5/17/10); see Table 44, p. 135
palivizumab – PA; see Table 37, p. 123              peginterfereon alfa-2b – PA > 4 doses/month; PA
palonosetron                                          (effective 5/17/10); see Table 44, p. 135
Pamelor # (nortriptyline) – see Table 17, p. 77     PEG-Intron (peginterfereon alfa-2b) – PA > 4
pamidronate                                           doses/month; PA (effective 5/17/10); see
Pamine # (methscopolamine)                            Table 44, p. 135
Pancrease MT (amylase/lipase/protease)              pegvisomant – PA
Pancrecarb (amylase/lipase/protease)                pemetrexed
Pancrelipase (amylase/lipase/protease)              pemirolast – PA; see Table 29, p. 107
Pancron (amylase/lipase/protease)                   penbutolol – PA; see Table 21, p. 91
Pandel (hydrocortisone) – PA; see Table 16,         penciclovir
  p. 74                                             penicillamine
Pangestyme (amylase/lipase/protease)                penicillin G
Panglobulin (immune globulin IV, human) – PA;       penicillin V – see Table 35, p. 118
  see Table 1, p. 39                                Penlac (ciclopirox) – PA; see Table 28, p. 105
panitumumab                                         Pentacel (diphtheria/tetanus toxoids/acellular
Panokase (amylase/lipase/protease)                    pertussis/poliovirus, inactivated/haemophilus b
Panretin (alitretinoin) – PA; see Table 10, p. 58     conjugate vaccine) – see Table 32, p. 114
pantoprazole ° – see Table 3, p. 43                 pentamidine
papaverine – PA                                     Pentasa (mesalamine)
                                                    pentazocine

May 3, 2010                                         26
Alphabetic List (cont.)

pentazocine/acetaminophen                       pioglitazone/metformin – PA; see Table 26, p. 101
pentazocine/naloxone – PA                       piperacillin/tazobactam
pentosan                                        piperonyl butoxide
pentoxifylline                                  pirbuterol – PA; see Table 23, p. 95
Pentoxil # (pentoxifylline)                     piroxicam – see Table 11, p. 61
Pepcid # (famotidine *) – see Table 3, p. 43    Plan B # (levonorgestrel)
P-Ephrine (phenylephrine)                       Plan B One Step (levonorgestrel)
peramavir H – see Table 39, p. 127              Plaquenil # (hydroxychloroquine)
Peranex HC (hydrocortisone/lidocaine) – PA;     Platinol-AQ # (cisplatin)
   see Table 16, p. 74                          Plavix (clopidogrel)
Percocet (oxycodone/acetaminophen) – PA; see    Plendil # (felodipine) – see Table 22, p. 93
   Table 8, p. 55                               plerixafor
Percodan # (oxycodone/aspirin) – see Table 8,   Pletal # (cilostazol)
   p. 55                                        Plexion (sulfacetamide/sulfur) – PA; see Table 10,
Perforomist (formoterol) – PA; see Table 23,      p. 58
   p. 95                                        pneumococcal conjugate vaccine – see Table 32,
Periactin # (cyproheptadine) – see Table 12,      p. 114
   p. 64                                        pneumococcal vaccine – see Table 32, p. 114
perindopril – PA; see Table 18, p. 81           pneumococcal 13-valent conjugate vaccine
Periostat # (doxycycline) – see Table 35,       Pneumovax (pneumococcal vaccine) – see
   p. 118                                         Table 32, p. 114
Perloxx (oxycodone/acetaminophen) – PA; see     Pnu-Imune # (pneumococcal vaccine)
   Table 8, p. 55                               podofilox
Permapen (penicillin G)                         poliovirus vaccine, inactivated – see Table 32, p. 114
permethrin *                                    Polycitra (citric acid/sodium citrate/potassium citrate)
perphenazine                                    Polycitra-K (citric acid/potassium citrate)
petrolatum *                                    Polycitra-LC (citric acid/sodium citrate/potassium
Pexeva (paroxetine) – PA; see Table 17, p. 77     citrate)
Pfizerpen # (penicillin G)                      polyethylene glycol
Pharmaflur (sodium fluoride)                    polyethylene glycol-electrolyte solution °
phenazopyridine                                 polyethylene glycol-electrolyte solution/bisacodyl – PA
phenelzine – see Table 17, p. 77                Polygam S/D (immune globulin IV, human) – PA; see
Phenergan # (promethazine) – see Table 12,        Table 1, p. 39
   p. 64                                        polymyxin B
phenobarbital – see Table 20, p. 86             Poly-Pred (neomycin/polymyxin B/prednisolone) – see
phentolamine – PA                                 Table 34, p. 117
phenylephrine                                   polythiazide
phenyltoloxamine/pyrilamine/pheniramine/        Polytrim # (trimethoprim/polymyxin B) – see Table 34,
   pseudoephedrine – see Table 12, p. 64          p. 117
Phenytek # (phenytoin) – see Table 20, p. 86    Ponstel (mefenamic acid) – PA; see Table 11, p. 61
phenytoin ° – see Table 20, p. 86               Portia (levonorgestrel/ethinyl estradiol)
phenytoin 100 mg/4 ml unit dose suspension –    posaconazole – PA; see Table 47, p. 141
   PA; see Table 20, p. 86                      potassium bicarbonate
Phisohex (hexachlorophene)                      potassium chloride/potassium bicarbonate
Phos-Flur (sodium fluoride)                     potassium chloride/sodium chloride/sodium
Phoslo # (calcium acetate)                        bicarbonate
Phospholine Iodide (echothiophate)              potassium citrate 5 meq, 10 meq
Phrenilin # (butalbital/acetaminophen)          potassium citrate 15 meq – PA
phytonadione                                    potassium citrate/citric acid
Pilocar # (pilocarpine)                         potassium citrate/sodium citrate/citric acid
pilocarpine                                     potassium iodide
pilocarpine/epinephrine                         potassium phosphate
Pilopine (pilocarpine)                          potassium phosphate/dibasic sodium
Piloptic (pilocarpine)                            phosphate/monobasic sodium phosphate
pimecrolimus – PA; see Table 42, p. 132         potassium phosphate/sodium phosphate
pimozide                                        potassium phosphate/sodium phosphate/phosphorus
pindolol – see Table 21, p. 91                  povidone *
pioglitazone – see Table 26, p. 101             pramipexole
                                                pralatrexate

May 3, 2010                                     27
Alphabetic List (cont.)

pramlintide – PA; see Table 45, p. 137              ProAir HFA (albuterol HFA) – see Table 23, p. 95
Prandimet (repaglinide/metformin) – PA; see         Proamatine (midodrine)
  Table 26, p. 101                                  probenecid
Prandin (repaglinide) – PA; see Table 26, p. 101    probenecid/colchicine
prasugrel                                           procainamide
Pravachol # (pravastatin) – PA > 30                 procarbazine
  units/month; see Table 13, p. 66                  Procardia # (nifedipine) – see Table 22, p. 93
pravastatin – PA > 30 units/month; see              Procentra (dextroamphetamine) – PA > 450
  Table 13, p. 66                                     ml/month; see Table 31, p. 111
prazosin – see Table 19, p. 84                      prochlorperazine
prazosin/polythiazide – see Table 19, p. 84         Procrit (epoetin alfa) – PA; see Table 4, p. 46
Precose # (acarbose) – see Table 26, p. 101         Proctocort # (hydrocortisone)
Pred-Forte # (prednisolone)                         Proctocream-HC # (pramoxine/hydrocortisone)
Pred-G (prednisolone/gentamicin) – see              Proctofoam-HC (pramoxine/hydrocortisone)
  Table 34, p. 117                                  Procto-Kit # (hydrocortisone)
prednicarbate – see Table 16, p. 74                 Proctozone-HC # (hydrocortisone)
prednisolone °                                      Profilnine SD (factor IX complex)
prednisolone, orally disintegrating tablet – PA     progesterone
prednisolone/gentamicin – see Table 34, p. 117      Proglycem (diazoxide)
prednisone                                          Prograf # (tacrolimus)
pregabalin – PA; see Table 20, p. 86                Prolastin (alpha1–proteinase inhibitor–human)
Prelone # (prednisolone)                            Prolixin # (fluphenazine)
Premarin (estrogens, conjugated)                    Proloprim # (trimethoprim) – see Table 35, p. 118
Premphase (medroxyprogesterone/estrogens,           Promacta (eltrombopag) – PA
  conjugated)                                       promethazine – see Table 12, p. 64
Prempro (medroxyprogesterone/estrogens,             promethazine/phenylephrine – see Table 12, p. 64
  conjugated)                                       Promethegan (promethazine)
prenatal vitamins *                                 Prometrium (progesterone)
Prevacid # (lansoprazole) capsule – PA > 2          Pronestyl # (procainamide)
  years; see Table 3, p. 43                         propafenone
Prevacid IV (lansoprazole) – PA; see Table 3,       propantheline
  p. 43                                             Propine # (dipivefrin)
Prevacid SoluTab (lansoprazole, orally              Proplex T (factor IX complex)
  disintegrating tablet) – PA > 2 years; see        propoxyphene – see Table 8, p. 55
  Table 3, p. 43                                    propoxyphene/acetaminophen – PA
Prevalite # (cholestyramine) – see Table 13,        propoxyphene napsylate – see Table 8, p. 55
  p. 66                                             propoxyphene napsylate/acetaminophen – see
Prevident (sodium fluoride)                           Table 8, p. 55
Prevnar (pneumococcal conjugate vaccine) –          propoxyphene powder – PA; see Table 8, p. 55
  see Table 32, p. 114                              propranolol – see Table 21, p. 91
Prevnar 13 (pneumococcal 13-valent conjugate        propranolol extended-release ° – see Table 21, p. 91
  vaccine) – see Table 32, p. 114                   propranolol/hydrochlorothiazide – see Table 21, p. 91
Prevpac                                             propylthiouracil
  (lansoprazole/amoxicillin/clarithromycin) – PA;   ProQuad (measles/mumps/rubella/varicella virus
  see Table 3, p. 43                                  vaccine) – see Table 32, p. 114
Prezista (darunavir) – see Table 38, p. 125         Proquin XR (ciprofloxacin, extended-release tablet) –
Prialt (ziconotide) – PA                              PA; see Table 35, p. 118
Prilosec (omeprazole) – PA; see Table 3, p. 43      Proscar (finasteride) – PA
primaquine                                          Prosed/DS (methenamine/benzoic/acid/
Primaxin (imipenem/cilastatin)                        atropine/hyoscyamine/saldol/methylene blue)
primidone – see Table 20, p. 86                     Prostigmin (neostigmine)
Primsol (trimethoprim) – see Table 35, p. 118       protein C concentrate – PA
Principen # (ampicillin) – see Table 35, p. 118     Protonix (pantoprazole) – PA; see Table 3, p. 43
Prinivil # (lisinopril) – see Table 18, p. 81       Protonix IV (pantoprazole) – see Table 3, p. 43
Prinzide # (lisinopril/hydrochlorothiazide) – see   Protopic (tacrolimus) – PA; see Table 42, p. 132
  Table 18, p. 81                                   protriptyline – see Table 17, p. 77
Pristiq (desvenlafaxine) – PA; see Table 17,        Proventil #
  p. 77                                             Proventil, inhaler (albuterol) – PA; see Table 23, p. 95


May 3, 2010                                         28
Alphabetic List (cont.)

Proventil HFA, inhaler (albuterol) – PA; see      Qvar (beclomethasone), inhaler – see Table 23, p. 95
  Table 23, p. 95
Provera # (medroxyprogesterone)                   R
Provigil (modafinil) – PA                         RabAvert (rabies vaccine) – see Table 32, p. 114
Prozac # (fluoxetine) – see Table 17, p. 77       rabeprazole – PA; see Table 3, p. 43
Prozac Weekly (fluoxetine) – PA; see Table 17,    rabies immune globulin IM, human – see Table 1,
  p. 77                                             p. 39
Prudoxin (doxepin)                                rabies vaccine – see Table 32, p. 114
pseudoephedrine * – PA > 240 mg/day               Radiacare (oxybenzone/pedimate)
Psorcon # (diflorasone) – see Table 16, p. 74     raloxifene
psyllium *                                        raltegravir – see Table 38, p. 125
Pulmicort (budesonide), inhalation suspension –   ramelteon – PA; see Table 15, p. 72
  see Table 23, p. 95                             ramipril ° – see Table 18, p. 81
Pulmicort (budesonide), inhaler – see Table 23,   Ranexa (ranolazine) – PA
  p. 95                                           ranibizumab ^
Pulmozyme (dornase alpha)                         ranitidine capsules – PA; see Table 3, p. 43
Purinethol # (mercaptopurine)                     ranitidine syrup – see Table 3, p. 43
Pylera (bismuth subcitrate/metronidazole/         ranitidine tablet * – see Table 3, p. 43
  tetracycline) – PA; see Table 3, p. 43          ranitidine, effervescent tablet – PA; see Table 3, p. 43
pyrazinamide                                      ranolazine – PA
pyrethrum                                         Rapaflo (silodosin) – PA; see Table 19, p. 84
Pyridium (phenazopyridine)                        Rapamune (sirolimus)
pyridostigmine bromide                            rasagiline
pyridoxine *                                      rasburicase
pyrilamine/phenylephrine – see Table 12, p. 64    Razadyne # (galantamine)
pyrimethamine                                     Razadyne ER # (galantamine, extended-release)
                                                  Rebetol # (ribavirin) – see Table 44, p. 135
Q
                                                  Rebetol solution (ribavirin) – PA > 18 years; see
QDall (chlorpheniramine/pseudoephedrine)            Table 44, p. 135
  – PA; see Table 12, p. 64                       Rebetron (interferon alfa-2b/ribavirin) – PA; see
QDall AR (chlorpheniramine, extended-release        Table 44, p. 135
  capsule) – PA; see Table 12, p. 64              Rebif (interferon beta-1a)
Qualaquin (quinine) – PA                          Reclast (zoledronic acid) – PA
quazepam – PA; see Table 15, p. 72                RectaGel HC (hydrocortisone/lidocaine) – PA; see
Questran # (cholestyramine) – see Table 13,         Table 16, p. 74
  p. 66                                           Recombinate (antihemophilic factor, recombinant)
quetiapine – PA > 90 units/month; see             Recombivax HB (hepatitis B, recombinant vaccine) –
  Table 24, p. 97                                   see Table 32, p. 114
quetiapine extended-release 150 mg and 200        Refacto (antihemophilic factor, recombinant)
  mg – PA > 30 units/month; see Table 24,         Refludan (lepirudin) – PA
  p. 97                                           Reglan # (metoclopramide)
quetiapine extended-release 50 mg, 300 mg         Regranex (becaplermin) – PA > 1 tube/month and
  and 400 mg – PA > 60 units/month; see             > 3 tubes/lifetime
  Table 24, p. 97                                 regular insulin, prefilled syringe – PA; see
Quibron (theophylline/guafenesin)                   Table 45, p. 137
Quibron-T/SR (theophylline)                       regular insulin, vial – see Table 45, p. 137
quinacrine                                        Relafen # (nabumetone) – see Table 11, p. 61
                                                                                                     st
Quinaglute # (quinidine)                          Relenza (zanamivir) – PA all quantities (June 1 to
                                                                     th
quinapril – see Table 18, p. 81                     September 30 ); PA > 20 inhalations/month or 40
quinapril/hydrochlorothiazide – see Table 18,       inhalations/season (October 1st to May 31st); see
  p. 81                                             Table 39, p. 127
Quinidex # (quinidine)                            Relistor (methylnaltrexone) – PA
quinidine                                         Relpax (eletriptan) – PA; see Table 14, p. 69
quinine – PA                                      Remeron # (mirtazapine) – see Table 17, p. 77
Quinzyme ODT (ubiquinone, orally disintegrating   Remeron Sol Tab (mirtazapine, orally disintegrating
  tablet) – PA                                      tablet) – PA; see Table 17, p. 77
Quixin (levofloxacin, ophthalmic) – PA; see       Remicade (infliximab) – PA; see Table 5, p. 48
  Table 34, p. 117                                Remodulin (treprostinil) – see Table 43, p. 133


May 3, 2010                                       29
Alphabetic List (cont.)

Renagel (sevelamer)                                 rilonacept – PA
Renese (polythiazide)                               Rilutek (riluzole)
Renvela (sevelamer)                                 riluzole
repaglinide – PA; see Table 26, p. 101              rimabotulinumtoxin B – PA; see Table 30, p. 109
repaglinide/metformin – PA; see Table 26,           Rimactane # (rifampin)
   p. 101                                           rimantadine
Repan # (butalbital/acetaminophen/caffeine)         rimexolone
Reprexain (hydrocodone/ibuprofen) – PA; see         Riomet (metformin solution) – see Table 26, p. 101
   Table 8, p. 55                                   risedronate – PA
Requip # (ropinirole)                               risedronate/calcium carbonate – PA
Requip Starter Kit (ropinirole) – PA                Risperdal # (risperidone) tablet – PA > 60
Requip XL (ropinirole extended-release) – PA           units/month; see Table 24, p. 97
Rescriptor (delavirdine) – see Table 38, p. 125     Risperdal # (risperidone) solution – PA > 480
reserpine                                              ml/month; see Table 24, p. 97
Restasis (cyclosporine, ophthalmic) – PA > 64       Risperdal Consta (risperidone injection) –
   units/month                                         PA > 2 units (2 syringes)/month; see
Restoril # 15 mg, 30 mg (temazepam) – PA > 30          Table 24, p. 97
   units/month; see Table 15, p. 72                 Risperdal M (risperidone, orally disintegrating tablet) –
Restoril 7.5 mg, 2.5 mg (temazepam) – PA; see          PA; see Table 24, p. 97
   Table 15, p. 72                                  risperidone injection – PA > 2 units (2
retapamulin – PA; see Table 41, p. 131                 syringes)/month; see Table 24, p. 97
Retin-A # (tretinoin) – PA > 21 years; see          risperidone tablet – PA > 60 units/month; see
   Table 10, p. 58                                     Table 24, p. 97
Retin-A Micro (tretinoin) – PA; see Table 10,       risperidone solution – PA > 480 ml/month; see
   p. 58                                               Table 24, p. 97
Retinol *                                           risperidone, orally disintegrating tablet – PA; see
Retisert ^ (fluocinolone)                              Table 24, p. 97
Retrovir # (zidovudine) – see Table 38, p. 125      Ritalin # (methylphenidate) – PA > 90 units/month;
Revatio (sildenafil) – PA; see Table 43, p. 133        see Table 31, p. 111
Revia # (naltrexone) – see Table 36, p. 120         Ritalin LA (methylphenidate extended-release) – PA >
Revlimid (lenalidomide)                                60 units/month; see Table 31, p. 111
Reyataz (atazanavir) – see Table 38, p. 125         Ritalin SR # (methylphenidate extended-release) – PA
Rheumatrex # (methotrexate)                            > 90 units/month; see Table 31, p. 111
Rhinocort Aqua (budesonide, nasal spray) – PA;      ritonavir capsule – see Table 38, p. 125
   see Table 25, p. 99                              ritonavir/lopinavir
Rho(D) immune globulin IM – see Table 1, p. 39      ritonavir tablet – PA; see Table 38, p. 125
Rho(D) immune globulin IM micro-dose – see          Rituxan (rituximab) – PA; see Table 5, p. 48
   Table 1, p. 39                                   rituximab – PA; see Table 5, p. 48
Rho(D) immune globulin IV, human – see              rivastigmine
   Table 1, p. 39                                   rizatriptan – PA; see Table 14, p. 69
RhoGAM (Rho(D) immune globulin IM) – see            rizatriptan, orally disintegrating tablets – PA; see
   Table 1, p. 39                                      Table 14, p. 69
RhoPhylac (Rho(D) immune globulin IV, human)        RMS (morphine) – see Table 8, p. 55
   – see Table 1, p. 39                             Robaxin # (methocarbamol) – see Table 7, p. 53
RiaSTAP (fibrinogen concentrate)                    Robinul # (glycopyrrolate)
Ribapak (ribavirin) – PA; see Table 44, p. 135      Rocaltrol # (calcitriol)
Ribasphere (ribavirin) 400 mg and 600 mg – PA;      Rocephin (ceftriaxone)
   see Table 44, p. 135                             romiplostim – PA
ribavirin ° – see Table 44, p. 135                  ropinirole °
ribavirin solution – PA > 18 years; see Table 44,   ropinirole extended-release – PA
   p. 135                                           rosiglitazone – see Table 26, p. 101
riboflavin *                                        rosiglitazone/metformin – PA; see Table 26, p. 101
Ridaura (auranofin)                                 rosuvastatin – PA; see Table 13, p. 66
rifabutin                                           Rotarix (rotavirus vaccine) – see Table 32, p. 114
Rifadin # (rifampin)                                RotaTeq (rotavirus vaccine) – see Table 32, p. 114
Rifamate (rifampin/isoniazid)                       rotavirus vaccine – see Table 32, p. 114
rifampin                                            Rowasa # (mesalamine)
rifampin/isoniazid                                  Roxanol (morphine) – PA > 360 mg/day; see
rifaximin – PA; see Table 35, p. 118                   Table 8, p. 55

May 3, 2010                                         30
Alphabetic List (cont.)

Roxanol-T (morphine) – PA > 360 mg/day; see      Selzentry (maraviroc) – PA; see Table 38, p. 125
  Table 8, p. 55                                 Semprex-D (acrivastine/pseudoephedrine) – PA; see
Roxicet (oxycodone/acetaminophen) – see             Table 12, p. 64
  Table 8, p. 55                                 senna *
Roxicodone (oxycodone) – PA > 240 mg/day;        Sensipar (cinacalcet)
  see Table 8, p. 55                             Sensorcaine # (bupivacaine)
Roxiprin (oxycodone/aspirin) – see Table 8,      Septisol (hexachlorophene)
  p. 55                                          Septra # (trimethoprim/sulfamethoxazole) – see
Rozerem (ramelteon) – PA; see Table 15, p. 72       Table 35, p. 118
rubella virus vaccine – see Table 32, p. 114     Serax # (oxazepam)
rufinamide – PA; see Table 20, p. 86             Serentil (mesoridazine)
Rx-Otic (antipyrine/benzocaine)                  Serevent (salmeterol) – PA; see Table 23, p. 95
Rythmol # (propafenone)                          Seroquel (quetiapine) – PA > 90 units/month; see
Ryzolt (tramadol extended-release) – PA             Table 24, p. 97
                                                 Seroquel XR (quetiapine extended-release) 150 mg
S                                                   and 200mg – PA > 30 units/month; see Table 24,
Sabril (vigabatrin) – PA; see Table 20, p. 86       p. 97
Saizen (somatropin) – PA; see Table 9, p. 56     Seroquel XR (quetiapine extended-release) 50 mg,
Salagen # (pilocarpine)                             300mg and 400mg – PA > 60 units/month; see
salicylic acid °                                    Table 24, p. 97
salicylic acid/sulfur colloidal                  Serostim (somatropin) – PA; see Table 9, p. 56
saliva substitute *                              sertaconazole – PA; see Table 28, p. 105
salmeterol – PA; see Table 23, p. 95             sertraline – see Table 17, p. 77
salsalate                                        sevelamer
Sal-Tropine (atropine)                           Shohl’s Solution (sodium citrate/citric acid)
Samsca (tolvaptan) – PA                          Sildec (carbinoxamine/pseudoephedrine)
Sanctura (trospium) – see Table 46, p. 139       sildenafil (Revatio) – PA; see Table 43, p. 133
Sanctura XR (trospium extended-release) – see    silodosin – PA; see Table 19, p. 84
  Table 46, p. 139                               Silvadene # (silver sulfadiazine)
Sancuso (granisetron transdermal system) –       silver sulfadiazine
  PA; see Table 27, p. 103                       Simcor (niacin extended-release/simvastatin) – PA;
Sandimmune # (cyclosorpine)                         see Table 13, p. 66
Sandoglobulin (immune globulin IV, human) –      simethicone *
  PA; see Table 1, p. 39                         Simponi (golimumab) – PA; see Table 5, p. 48
Sandostatin # (octreotide)                       simple syrup
Sansert (methysergide)                           simvastatin – PA > 30 units/month; see
Santyl (collagenase)                                Table 13, p. 66
Saphris (asenapine) – PA; see Table 24, p. 97    simvastatin/niacin extended-release – PA; see
sapropterin                                         Table 13, p. 66
saquinavir – see Table 38, p. 125                sinecatechins – PA
Sarafem (fluoxetine) – PA; see Table 17, p. 77   Sinemet # (carbidopa/levodopa)
sargramostim – see Table 4, p. 46                Sinequan # (doxepin) – see Table 17, p. 77
Savella (milnacipran) – PA                       Singulair (montelukast) – PA > 16 years; PA
saxagliptin – PA                                    (effective 5/17/10); see Table 40, p. 129
scopolamine                                      sirolimus
scopolamine/phenylephrine                        sitagliptin – PA; see Table 26, p. 101
Seasonale # (ethinyl estradiol/levonorgestrel)   sitagliptin/metformin – PA; see Table 26, p. 101
Seasonique (ethinyl estradiol/levonorgestrel)    Skelaxin (metaxalone) – PA; see Table 7, p. 53
secobarbital                                     Skelid (tiludronate) – PA
secobarbital/amobarbital                         Slo-Bid # (theophylline)
Seconal # (secobarbital)                         Slo-Phyllin (theophylline)
Sectral # (acebutolol) – see Table 21, p. 91     sodium benzoate/sodium phenylacetate
selegiline                                       sodium bicarbonate *
selegiline, orally disintegrating tablet – PA    sodium chloride solution for inhalation *
selegiline transdermal system – PA; see          sodium citrate/citric acid
  Table 17, p. 77                                sodium ferric gluconate complex
selenium sulfide                                 sodium fluoride
                                                 sodium oxybate – PA
                                                 sodium phenylbutyrate

May 3, 2010                                      31
Alphabetic List (cont.)

sodium phosphate °                                  Suboxone (buprenorphine/naloxone) > 16 and
sodium polystyrene sulfonate                          < 24 mg/day – PA > 180 days; see Table 36, p. 120
Solaraze (diclofenac) – PA; see Table 11, p. 61     Suboxone (buprenorphine/naloxone) < 16 mg/day; see
Solganal (aurothioglucose)                            Table 36, p. 120
solifenacin 5 mg – PA > 30 units/month; see         Subutex (buprenorphine) – PA; see Table 36, p. 120
  Table 46, p. 139                                  succimer
solifenacin 10 mg – see Table 46, p. 139            sucralfate
Soliris (eculizumab) – PA                           sufentanil powder – PA; see Table 8, p. 55
Solodyn (minocycline extended release) – PA;        Sular (nisoldipine) – PA; see Table 22, p. 93
  see Table 10, p. 58; see Table 35, p. 118         sulconazole – PA; see Table 28, p. 105
Soltamox (tamoxifen) – PA                           sulfacetamide, topical – PA > 21 years; see
Solu-Cortef # (hydrocortisone)                        Table 10, p. 58
Solu-Medrol # (methylprednisolone)                  sulfacetamide, ophthalmic – see Table 34, p. 117
Soma (carisoprodol) – PA; see Table 7, p. 53        sulfacetamide/prednisolone – see Table 34, p. 117
Soma Compound (carisoprodol/aspirin) – PA;          sulfacetamide/sulfur – PA; see Table 10, p. 58
  see Table 7, p. 53                                Sulfacet-R (sulfacetamide/sulfur) – PA; see Table 10,
Soma Compound/Codeine                                 p. 58
  (carisoprodol/aspirin/codeine) – PA; see          sulfadiazine – see Table 35, p. 118
  Table 7, p. 53                                    Sulfamide (sulfacetamide)
somatropin – PA; see Table 9, p. 56                 Sulfamylon (mafenide)
Somatuline (lanreotide)                             sulfanilamide
Somavert (pegvisomant) – PA                         sulfasalazine
Somnote (chloral hydrate)                           Sulfatrim (trimethoprim/sulfamethoxazole) – see
Sonata # (zaleplon) – PA > 30 units/month; see        Table 35, p. 118
  Table 15, p. 72                                   Sulfazine # (sulfasalazine)
sorafenib                                           sulfinpyrazone
Sorbitrate # (isosorbide)                           sulfisoxazole – see Table 35, p. 118
Soriatane (acitretin) – see Table 10, p. 58         Sulfoxyl (benzoyl peroxide/sulfur) – PA; see
sotalol – see Table 21, p. 91                         Table 10, p. 58
Sotret (isotretinoin) – PA > 21 years; see          sulindac – see Table 11, p. 61
  Table 10, p. 58                                   sumatriptan, injection – PA; see Table 14, p. 69
Spectazole # (econazole) – see Table 28, p. 105     sumatriptan, nasal spray – PA; see Table 14, p. 69
Spectracef (cefditoren) – see Table 35, p. 118      sumatriptan, tablet – PA > 9 units/month; see
Spiriva (tiotropium)                                  Table 14, p. 69
spironolactone – see Table 33, p. 116               sumatriptan/naproxen – PA; see Table 14, p. 69
spironolactone/hydrochlorothiazide                  Sumycin # (tetracycline) – see Table 35, p. 118
Sporanox # (itraconazole) – see Table 47,           Sunitinib
  p. 141                                            Supprelin LA (histrelin) – PA; see Table 2, p. 41
Sprintec (ethinyl estradiol/norgestimate)           Suprax (cefixime) – see Table 35, p. 118
Sprycel (dasatinib)                                 Surmontil # (trimipramine) – see Table 17, p. 77
SPS # (sodium polystyrene sulfonate)                Sustiva (efavirenz) – see Table 38, p. 125
SSKI (potassium iodide)                             Sutent (sunitinib)
Stadol, injection # (butorphanol)                   Symbicort (budesonide/formoterol) – PA; see
Stadol, nasal spray (butorphanol) – PA                Table 23, p. 95
Stalevo (carbidopa/levodopa/entacapone) – PA        Symbyax (fluoxetine/olanzapine) – PA; see
stanozolol                                            Table 17, p. 77; see Table 24, p. 97
Starlix (nateglinide) – PA; see Table 26, p. 101    Symlin (pramlintide) – PA; see Table 45, p. 137
stavudine – see Table 38, p. 125                    Symmetrel # (amantadine)
Stavzor (valproic acid) – PA; see Table 20, p. 86   Synagis (palivizumab) – PA; see Table 37, p. 123
Stelara (ustekinumab) – PA; see Table 5, p. 48      Synalar # (fluocinolone) – see Table 16, p. 74
Stimate (desmopressin)                              Synalgos-DC (dihydrocodeine/aspirin/caffeine)
Strattera (atomoxetine) – PA; – see Table 31,       Synarel (nafarelin) – PA; see Table 2, p. 41
  p. 111                                            Synera (lidocaine/tetracaine) – PA > 4 patches
Stromectol (ivermectin)                               month
Suboxone (buprenorphine/naloxone)                   Synercid (dalfopristin/quinpristin)
  > 32mg/day – PA; see Table 36, p. 120             Synthroid # (levothyroxine)
Suboxone (buprenorphine/naloxone) > 24 and          Syprine (trientine)
  < 32 mg/day – PA > 90 days ; see Table 36,
  p. 120

May 3, 2010                                         32
Alphabetic List (cont.)

T                                                 Temodar (temozolomide)
                                                  Temovate # (clobetasol) – see Table 16, p. 74
tacrine
                                                  temozolomide
Taclonex (betamethasone/calcipotriene) – PA
                                                  temsirolimus
tacrolimus ° – see Table 42, p. 132
                                                  Tenex # (guanfacine)
tadalafil (Adcirca) – PA; see Table 43, p. 133
                                                  tenofovir – PA > 30 units/month (effective 05/17/10);
Tagamet # (cimetidine *) – see Table 3, p. 43
                                                    see Table 38, p. 125
Talacen # (pentazocine/acetaminophen)
                                                  Tenoretic # (atenolol/chlorthalidone) – see Table 21,
Talwin (pentazocine)
                                                    p. 91
Talwin NX # (pentazocine/naloxone) – PA
                                                  Tenormin # (atenolol) – see Table 21, p. 91
Tambocor # (flecainide)
                                                  Terak (oxytetracycline/polymyxin B)
Tamiflu 30 mg (oseltamivir) – PA all quantities
                                                  Terazol # (terconazole)
  (June 1st to September 30th); PA > 20
                                                  terazosin – see Table 19, p. 84
  capsules/month and PA > 40
                                                  terbinafine granules – PA; see Table 47, p. 141
  capsules/season (October 1st to May 31st);
                                                  terbinafine tablet – see Table 47, p. 141
  see Table 39, p. 127
                                                  terbinafine, topical – PA; see Table 28, p. 105
Tamiflu 45 mg and 75 mg (oseltamivir) – PA all
                                                  terbutaline
  quantities (June 1st to September 30th);
                                                  terconazole
  PA > 10 capsules/month and PA > 20
                                                  teriparatide – PA
  capsules/season (October 1st to May 31st);
                                                  Testim (testosterone)
  see Table 39, p. 127
                                                  Testoderm (testosterone)
Tamiflu (oseltamivir) suspension – PA all
                                                  Testopel Pellet (testosterone)
  quantities (June 1st to September 30th); PA
                                                  testosterone
  > 75 ml/month and PA > 150 ml/season
                                                  Testred (methyltestosterone)
  (October 1st to May 31st); see Table 39,
                                                  tetanus immune globulin IM, human – see Table 1,
  p. 127
                                                    p. 39
tamoxifen °
                                                  tetrabenazine – PA
tamsulosin – PA; see Table 19, p. 84
                                                  tetracycline – see Table 10, p. 58; see Table 35,
TAO (troleandomycin)
                                                    p. 118
Tapazole # (methimazole)
                                                  Tev-Tropin (somatropin) – PA; see Table 9, p. 56
tapentadol – PA see Table 8, p. 55
                                                  Teveten (eprosartan) – PA; see Table 18, p. 81
Tarceva (erlotinib)
                                                  Tevetan HCT (eprosartan/hydrochlorothiazide) – PA;
Targretin (bexarotene)
                                                    see Table 18, p. 81
Tarka (trandolapril/verapamil) – PA; see
                                                  Texacort # (hydrocortisone) – see Table 16, p. 74
  Table 18, p. 81; see Table 22, p. 93
                                                  thalidomide
Tasigna (nilotinib)
                                                  Thalitone (chlorthalidone)
Tasmar (tolcapone)
                                                  Thalomid (thalidomide)
Tavist # (clemastine) – see Table 12, p. 64
                                                  Theo-24 (theophylline)
Taxol # (paclitaxel)
                                                  Theochron # (theophylline)
Taxotere (docetaxel)
                                                  Theo-Dur # (theophylline)
tazarotene – PA; see Table 10, p. 58
                                                  Theolair (theophylline)
Tazicef # (ceftazidime)
                                                  Theolair-SR # (theophylline)
Tazidime # (ceftazidime)
                                                  Theolate (theophylline/guaifenesin)
Tazorac (tazarotene) – PA; see Table 10, p. 58
                                                  theophylline
Tegretol # (carbamazepine) – see Table 20,
                                                  theophylline/guaifenesin
  p. 86
                                                  theophylline/potassium iodide
Tekturna (aliskiren) – PA; see Table 18, p. 81
                                                  Thera-Flur-N (sodium fluoride)
Tekturna HCT (aliskiren/hydrochlorothiazide) –
                                                  TheraCys (BCG vaccine) – see Table 32, p. 114
  PA; see Table 18, p. 81
                                                  Thermazene # (silver sulfadiazine)
telbivudine – PA > 30 units/month; see
                                                  thiabendazole
  Table 44, p. 135
                                                  thiamine *
telithromycin – PA; see Table 35, p. 118
                                                  thiethylperazine
telmisartan – PA; see Table 18, p. 81
                                                  thioguanine
telmisartan/hydrochlorothiazide – PA; see
                                                  Thiola (tiopronin)
  Table 18, p. 81
                                                  thioridazine
temazepam 15 mg, 30 mg – PA > 30
                                                  thiotepa
  units/month; see Table 15, p. 72
                                                  thiothixene
temazepam 7.5 mg, 22.5 mg – PA; see
                                                  Thorazine # (chlorpromazine)
  Table 15, p. 72


May 3, 2010                                       33
Alphabetic List (cont.)

Thymoglobulin (antithymocyte globulin, rabbit) –   Tonocard (tocainide)
   see Table 1, p. 39                              Topamax # (topiramate) – PA > 18 years; see
thyroid                                               Table 20, p. 86
Thyrolar (liotrix)                                 Topicort # (desoximetasone) – see Table 16, p. 74
Thyrox (levothyroxine)                             Topicort LP # (desoximetasone) – see Table 16, p. 74
tiagabine – PA > 18 years; see Table 20, p. 86     topiramate – PA > 18 years; see Table 20, p. 86
Tiazac # (diltiazem) – see Table 22, p. 93         topotecan
ticarcillin/clavulanate                            Toprol XL # (metoprolol) – see Table 21, p. 91
TICE BCG (BCG vaccine) – see Table 32,             Toradol # (ketorolac) – PA > 20 units/month); see
   p. 114                                             Table 11, p. 61
Ticlid # (ticlopidine)                             Torecan (thiethylperazine)
ticlopidine                                        toremifene
Tigan # (trimethobenzamide) 300 mg, 100            Torisel (temsirolimus)
   mg/ml                                           torsemide
tigecycline                                        tositumomab – PA
Tikosyn (dofetilide)                               Toviaz 4 mg (fesoterodine) – PA > 30 units/month;
Tilade (nedocromil) – see Table 23, p. 95             see Table 46, p. 139
tiludronate – PA                                   Toviaz 8 mg (fesoterodine) – see Table 46, p. 139
Timentin (ticarcillin/clavulanate)                 T-Phyl (theophylline)
timolol – see Table 21, p. 91                      Tracleer (bosentan) – see Table 43, p. 133
timolol/hydroclorothiazide – see Table 21, p. 91   tramadol
Timoptic # (timolol)                               tramadol extended-release – PA
Tindamax (tinidazole) – PA                         tramadol/acetaminophen – PA
tinidazole – PA                                    Trandate # (labetalol) – see Table 21, p. 91
tiopronin                                          trandolapril – see Table 18, p. 81
tiotropium                                         trandolapril/verapamil – PA; see Table 18, p. 81; see
tipranavir – see Table 38, p. 125                     Table 22, p. 93
                                                                      H
tizanidine ° – see Table 7, p. 53                  tranexamic acid
TOBI (tobramycin/sodium chloride)                  Transderm-Nitro (nitroglycerin)
TobraDex (tobramycin/dexamethasone) – see          Transderm-Scop (scopolamine)
   Table 34, p. 117                                Tranxene SD (clorazepate) – PA; see Table 20, p. 86
tobramycin                                         Tranxene T # (clorazepate) – see Table 20, p. 86
tobramycin, ophthalmic ointment – PA; see          tranylcypromine – see Table 17, p. 77
   Table 34, p. 117                                trastuzumab
tobramycin, ophthalmic solution – see Table 34,    Travasol (amino acid and electrolyte IV infusion)
   p. 117                                          Travatan (travoprost) – PA
tobramycin/dexamethasone – see Table 34,           travoprost – PA
   p. 117                                          trazodone ° – see Table 17, p. 77
tobramycin/sodium chloride                         Treanda (bendamustine)
Tobrex (tobramycin) ophthalmic ointment – PA;      Trelstar (triptorelin) – PA; see Table 2, p. 41
   see Table 34, p. 117                            Trental # (pentoxifylline)
Tobrex # (tobramycin) ophthalmic solution – see    treprostinil– see Table 43, p. 133
   Table 34, p. 117                                tretinoin ° – see Table 10, p. 58
tocainide                                          Trexall (methotrexate)
toclizumab – PA; see Table 5, p. 48                Treximet (sumatriptan/naproxen) – PA; see Table 14,
Tofranil # (imipramine) – see Table 17, p. 77         p. 69
tolazamide – see Table 26, p. 101                  triamcinolone, inhaler – see Table 23, p. 95
tolbutamide – see Table 26, p. 101                 triamcinolone, nasal spray – PA; PA > 4 years and 1
tolcapone                                             inhaler/month; see Table 25, p. 99
Tolectin # (tolmetin) – see Table 11, p. 61        triamcinolone, oral
Tolinase # (tolazamide) – see Table 26, p. 101     triamcinolone, topical ° – see Table 16, p. 74
tolmetin – see Table 11, p. 61                     triamterene/hydrochlorothiazide
tolnaftate * – see Table 28, p. 105                Triaz (benzoyl peroxide) – PA; see Table 10, p. 58
tolterodine – see Table 46, p. 139                 triazolam – PA > 30 units/month; see Table 15, p. 72
tolterodine extended-release 2 mg – PA >30         Tri-Chlor (trichloroacetic acid)
   units/month; see Table 46, p. 139               trichlormethiazide
tolterodine extended-release 4 mg – see            trichloroacetic acid
   Table 46, p. 139                                Tricor (fenofibrate) – PA; see Table 13, p. 66
tolvaptan – PA                                     trientine

May 3, 2010                                        34
Alphabetic List (cont.)

triethanolamine                                     Tyzeka (telbivudine) – PA > 30 units/month; see
trifluoperazine                                       Table 44, p. 135
trifluridine
Triglide (fenofibrate) – PA; see Table 13, p. 66    U
trihexyphenidyl                                     ubiquinone, orally disintegrating tablet – PA
TriHIBit (diphtheria/tetanus toxoids/acellular      U-Cort (hydrocortisone/urea)
   pertussis/haemophilus influenza b conjugate      Udamin (folic acid/multivitamin) – PA
   vaccine) – see Table 32, p. 114                  Udamin SP (folic acid/multivitamin/saw palmetto) – PA
Trilafon # (perphenazine)                           Ulesfia (benzyl alcohol lotion)
Trileptal # (oxcarbazepine) – see Table 20, p. 86   Uloric (febuxostat) – PA
Tri-Levlen # (ethinyl estradiol/levonorgestrel)     Ultracet (tramadol/acetaminophen) – PA
Trilipix (fenofibric acid) – PA; see Table 13,      Ultram # (tramadol)
   p. 66                                            Ultram ER (tramadol extended-release) – PA
trimethobenzamide 300 mg, 100 mg/ml                 Ultrase (amylase/lipase/protease)
trimethoprim – see Table 35, p. 118                 Ultravate # (halobetasol) – see Table 16, p. 74
trimethoprim/polymyxin B – see Table 34, p. 117     Unasyn # (ampicillin/sulbactam)
trimethoprim/sulfamethoxazole – see Table 10,       Uni-Dur (theophylline)
   p. 58; see Table 35, p. 118                      Uniphyl # (theophylline)
trimipramine – see Table 17, p. 77                  Uniretic # (moexipril/hydrochlorothiazide) – see
Trimox # (amoxicillin) – see Table 35, p. 118         Table 18, p. 81
Tri-Norinyl # (ethinyl estradiol/norethindrone)     Unithroid # (levothyroxine)
Tripedia (diphtheria/tetanus toxoids/acellular      Univasc # (moexipril) – see Table 18, p. 81
   pertussis vaccine) – see Table 32, p. 114        urea/sodium proprionate/methionine/cystine/
Triphasil # (ethinyl estradiol/levonorgestrel)        inositol
triprolidine/pseudoephedrine                        Urecholine (bethanechol)
triptorelin – PA; see Table 2, p. 41                Urex # (methenamine)
Tri-Sprintec (ethinyl estradiol/norgestimate)       Urispas # (flavoxate) – see Table 46, p. 139
Tri-Statin II (nystatin/triamcinolone)              Urocit-K 5 meq, 10 meq # (potassium citrate)
Trivora (ethinyl estradiol/levonorgestrel)          Urocit-K 15 meq (potassium citrate) – PA
Trizivir (abacavir/lamivudine/zidovudine) – see     Uroqid-Acid No. 2 (methenamine/sodium biphosphate)
   Table 38, p. 125                                 Uroxatral (alfuzosin) – PA; see Table 19, p. 84
troleandomycin                                      URSO # (ursodiol)
tropicamide                                         URSO Forte (ursodiol)
trospium – see Table 46, p. 139                     Ursodiol
trospium extended release – see Table 46,           ustekinumab – PA; see Table 5, p. 48
   p. 139
Trusopt # (dorzolamide)                             V
Truvada (emtricitabine/tenofovir) – see Table 38,   Vagifem (estradiol)
   p. 125                                           valacyclovir
Trycet (propoxyphene/acetaminophen) – PA;           Valcyte (valganciclovir)
   see Table 8, p. 55                               valganciclovir
Tuinal (secobarbital/amobarbital)                   Valisone # (betamethasone) – see Table 16, p. 74
Twinrix (hepatitis A, inactivated/hepatitis B,      valproate – see Table 20, p. 86
   recombinant vaccine) – see Table 32, p. 114      valproic acid ° – see Table 20, p. 86
Twynsta (amlodipine/telmisartan) – PA; see          valrubicin
   Table 18, p. 81; see Table 22, p. 93             valsartan – PA; see Table 18, p. 81
Tygacil (tigecycline)                               valsartan/hydrochlorothiazide – PA; see Table 18,
Tykerb (lapatinib)                                    p. 81
Tylenol/codeine # (codeine/acetaminophen) –         Valstar (valrubicin)
   see Table 8, p. 55                               Valtrex (valacyclovir)
Tylox # (oxycodone/acetaminophen) – see             Valturna (aliskiren/valsartan) – PA; see Table 18, p. 81
   Table 8, p. 55                                   Vancocin (vancomycin), injection – see Table 35,
Typhim Vi (typhoid vaccine) – see Table 32,           p. 118
   p. 114                                            Vancocin (vancomycin), capsule – PA
typhoid vaccine – see Table 32, p. 114                (effective 05/17/10); see Table 35, p. 118
Tysabri (natalizumab)                               Vancoled # (vancomycin)
Tyvaso (treprostinil) – see Table 43, p. 133        vancomycin, capsule – PA
                                                      (effective 05/17/10); see Table 35, p. 118


May 3, 2010                                         35
Alphabetic List (cont.)

vancomycin, injection – see Table 35, p. 118        Vibramycin # (doxycyline) – see Table 35, p. 118
Vanos (fluocinonide) – PA; see Table 16, p. 74      Vicodin # (hydrocodone/acetaminophen) – see
Vantas (histrelin) – PA; see Table 2, p. 41            Table 8, p. 55
Vantin # (cefpodoxime) – see Table 35, p. 118       Vicoprofen # (hydrocodone/ibuprofen)
Vaprisol (conivaptan) H                             Victoza (liraglutide) – PA; see Table 45, p. 137
VAQTA (hepatitis A vaccine, inactivated) – see      vidarabine
  Table 32, p. 114                                  Vidaza (azacitidine)
varenicline – PA > 24 weeks/year; see Table 6,      Videx # (didanosine) – see Table 38, p. 125
  p. 51                                             vigabatrin – PA; see Table 20, p. 86
varicella virus vaccine – see Table 32, p. 114      Vigamox (moxifloxacin, ophthalmic) – PA; see
varicella-zoster immune globulin IM, human –           Table 34, p. 117
  see Table 1, p. 39                                Vimpat injection (lacosamide) – see Table 20, p. 86
Varivax (varicella virus vaccine) – see Table 32,   Vimpat tablet (lacosamide) – PA; see Table 20, p. 86
  p. 114                                            vinblastine
Vaseretic # (enalapril/hydrochlorothiazide) – see   vincristine
  Table 18, p. 81                                   vinorelbine
vasopressin                                         Viokase (amylase/lipase/protease)
Vasotec # (enalapril) – see Table 18, p. 81         Vira-A (vidarabine)
Vectibix (panitumumab)                              Viracept (nelfinavir) – see Table 38, p. 125
Vectical (calcitrol ointment) – PA                  Viramune (nevirapine) – see Table 38, p. 125
Veetids # (penicillin V) – see Table 35, p. 118     Viread (tenofovir) – PA > 30 units/month
Velcade (bortezomib)                                   (effective 05/17/10); see Table 38, p. 125
Velivet (ethinyl estradiol/desogestrel)             Viroptic # (trifluridine)
venlafaxine – see Table 17, p. 77                   Visicol (sodium phosphate) – PA
venlafaxine extended-release capsule – PA; see      Visine-A (naphazoline/pheniramine) – see
  Table 17, p. 77                                      Table 29, p. 107
venlafaxine extended-release tablet – see           Visken # (pindolol) – see Table 21, p. 91
  Table 17, p. 77                                   Vistaril # (hydroxyzine) – see Table 12, p. 64
Venofer (iron sucrose)                              Vistide (cidofovir)
Venoglobulin-I (immune globulin IV, human) –        Visudyne (verteporfin)
  PA; see Table 1, p. 39                            vitamin A * (retinol)
Venoglobulin-S (immune globulin IV, human) –        vitamin B1 * (thiamine)
  PA; see Table 1, p. 39                            vitamin B2 * (riboflavin)
Ventavis (iloprost) – see Table 43, p. 133          vitamin B3 * (niacin)
Ventolin # (albuterol)                              vitamin B6 * (pyridoxine)
Ventolin, inhaler (albuterol) – PA; see Table 23,   vitamin B12 * (cyanocobalamin)
  p. 95                                             vitamin B complex *
Ventolin HFA, inhaler (albuterol) – PA; see         vitamin C *
  Table 23, p. 95                                   vitamin D *
Vepesid # (etoposide)                               vitamin D/dihydrotachysterol/ergocalciferol
Veramyst (fluticasone furoate), nasal spray –       vitamin E, oral *
  PA; see Table 25, p. 99                           vitamins, multiple *
verapamil – see Table 22, p. 93                     vitamins, multiple/minerals *
Verdeso (desonide) – PA; see Table 16, p. 74        vitamins, pediatric *
Veregen (sinecatechins) – PA                        vitamins, prenatal *
Verelan # (verapamil) – see Table 22, p. 93         Vivactil # (protriptyline) – see Table 17, p. 77
Veripred (prednisolone) – PA                        Vivaglobin (immune globulin, subcutaneous) – PA; see
Vermox # (mebendazole)                                 Table 1, p. 39
Versed # (midazolam)                                Vivelle # (estradiol)
verteporfin                                         Vivelle-Dot (estradiol)
VESIcare 5 mg (solifenacin) – PA > 30               Vivitrol (naltrexone injection) – PA; see
  units/month; see Table 46, p. 139                    Table 36, p. 120
VESIcare 10 mg (solifenacin) – see Table 46,        Vivotif Berna Vaccine (typhoid vaccine) – see
  p. 139                                               Table 32, p. 114
Vexol (rimexolone)                                  Volmax (albuterol)
VFend (voriconazole), suspension, tablet – PA;      Voltaren # (diclofenac) – see Table 11, p. 61
  see Table 47, p. 141                              Voltaren Gel (diclofenac topical gel) – PA; see
VFend IV (voriconazole)                                Table 11, p. 61
Viadur (leuprolide) – PA; see Table 2, p. 41

May 3, 2010                                         36
Alphabetic List (cont.)

Voltaren XR # (diclofenac extended-release) –       Xyralid (hydrocortisone/lidocaine) – PA; see Table 16,
  PA; see Table 11, p. 61                            p. 74
von Willebrand Factor/Coagulation Factor VIII       Xyrem (sodium oxybate) – PA
  Complex                                           Xyzal (levocetirizine) – PA; see Table 12, p. 64
voriconazole ° – see Table 47, p. 141
vorinostat                                          Y
Vosol # (acetic acid)                               Yasmin # (ethinyl estradiol/drospirenone)
Votrient (pazopanib)                                Yaz (ethinyl estradiol/drospirenone)
Vusion (miconazole/zinc oxide) – PA; see            yellow fever vaccine – see Table 32, p. 114
  Table 28, p. 105                                  YF-Vax (yellow fever vaccine) – see Table 32, p. 114
Vytorin (ezetimibe/simvastatin) – PA; see
  Table 13, p. 66                                   Z
Vyvanse (lisdexamfetamine) – PA; see                zafirlukast – PA > 16 years; PA (effective 5/17/10);
  Table 31, p. 111                                     see Table 40, p. 129
                                                    zaleplon – PA > 30 units/month; see Table 15, p. 72
W                                                   Zanaflex (tizanidine) capsule – PA; see Table 7, p. 53
warfarin                                            Zanaflex # (tizanidine) tablet – see Table 7, p. 53
water for inhalation *                              zanamivir – PA all quantities (June 1st to
Welchol (colesevelam), tablet – PA                     September 30th); PA > 20 inhalations/month or 40
  (effective 5/17/10); see Table 13, p. 66; see        inhalations/season (October 1 st to May 31 st); see
  Table 26, p. 101                                     Table 39, p. 127
Welchol (colesevelam) powder for suspension –       Zantac # (ranitidine *) – see Table 3, p. 43
  PA; see Table 13, p. 66                           Zantac EFFERdose (ranitidine, effervescent tablet) –
Wellbutrin # (bupropion) – see Table 17, p. 77         PA; see Table 3, p. 43
Wellbutrin SR # (bupropion sustained–release) –     Zarontin # (ethosuximide) – see Table 20, p. 86
  see Table 17, p. 77                               Zaroxolyn # (metolazone)
Wellbutrin XL (bupropion extended–release) – PA;    Zavesca (miglustat)
  see Table 17, p. 77                               Zebeta # (bisoprolol) – see Table 21, p. 91
Westcort # (hydrocortisone) – see Table 16,         Zebutal (butalbital/acetaminophen/caffeine)
  p. 74                                             Zelapar (selegiline, orally disintegrating tablet) – PA
Wilate (von Willebrand Factor/Coagulation           Zemaira (alpha1–proteinase inhibitor–human)
  Factor VIII Complex)                              Zemplar (paricalcitol)
WinRho SDF (Rho(D) immune globulin IV,              Zenapax (daclizumab)
  human) – see Table 1, p. 39                       Zenpep (pancrelipase)
Winstrol (stanozolol)                               Zerit # (stavudine) – see Table 38, p. 125
witch hazel *                                       Zervalx (L-methylfolate) – PA
Wycillin (penicillin G)                             Zestoretic # (lisinopril/hydrochlorothiazide) – see
                                                       Table 18, p. 81
X                                                   Zestril # (lisinopril) – see Table 18, p. 81
Xalatan (latanoprost) – PA                          Zetia (ezetimibe) – PA; see Table 13, p. 66
Xanax # (alprazolam)                                Zevalin (ibritumomab) – PA
Xanax XR (alprazolam extended-release) – PA         Ziac # (bisoprolol/hydrochlorothiazide) – see
Xeloda (capecitabine)                                  Table 21, p. 91
Xenazine (tetrabenazine) – PA                       Ziagen (abacavir) – see Table 38, p. 125
Xibrom (bromfenac) – PA                             Ziana (clindamycin/tretinoin) – PA; see Table 10, p. 58
Xifaxan (rifaximin) – PA; see Table 35, p. 118      ziconotide – PA
Xodol (hydrocodone/acetaminophen) – PA; see         zidovudine – see Table 38, p. 125
  Table 8, p. 55                                    zileuton extended-release – PA; see Table 40, p. 129
Xolair (omalizumab) – PA                            Zinacef # (cefuroxime)
Xolegel (ketoconazole) – PA; see Table 28,          zinc oxide *
  p. 105                                            zinc sulfate
Xopenex (levalbuterol), inhalation solution – PA;   Zincate (zinc sulfate)
  see Table 23, p. 95                               Zinecard (dexrazoxane)
Xopenex HFA (levalbuterol), inhaler – PA; see       ziprasidone – PA > 60 units/month; see Table 24,
  Table 23, p. 95                                      p. 97
Xylocaine # (lidocaine)                             Zipsor (diclofenac) – PA; see Table 11, p. 61
Xylocaine-MPF # (lidocaine)                         Zithromax # (azithromycin) – see Table 35, p. 118
Xyntha (antihemophilic factor, recombinant)         Zmax (azithromycin) – see Table 35, p. 118


May 3, 2010                                         37
Alphabetic List (cont.)

Zocor # (simvastatin) – PA > 30 units/month;         Zyprexa (olanzapine) – PA > 30 units/month; see
  see Table 13, p. 66                                  Table 24, p. 97
ZoDerm (benzoyl peroxide) – PA; see Table 10,        Zyprexa IM (olanzapine injection) – see Table 24,
  p. 58                                                p. 97
Zofran # (ondansetron) 4 mg, 8 mg – PA > 15          Zyprexa Relprevv (olanzapine pamoate) 210 mg, 300
  units/month; see Table 27, p. 103                    mg – PA > 2 injections/month; see Table 24, p. 97
Zofran # (ondansetron) – 24 mg – PA > 5              Zyprexa Relprevv (olanzapine pamoate) 405 mg – PA
  units/month; see Table 27, p. 103                    > 1 injection/month; see Table 24, p. 97
Zofran # (ondansetron) injection – see Table 27,     Zyprexa Zydis (olanzapine, orally disintegrating
  p. 103                                               tablets) – PA; see Table 24, p. 97
Zofran # (ondansetron) solution – PA > 50            Zytopic (triamcinolone) – PA; see Table 16, p. 74
  ml/month; see Table 27, p. 103                     Zyvox IV (linezolid)
Zofran ODT (ondansetron, orally disintegrating       Zyvox (linezolid), suspension – PA; see Table 35,
  tablet) – PA; see Table 27, p. 103                   p. 118
Zoladex (goserelin) – PA; see Table 2, p. 41         Zyvox (linezolid), tablet – PA; see Table 35, p. 118
zoledronic acid °
Zolinza (vorinostat)
zolmitriptan, nasal spray – PA; see Table 14,
  p. 69
zolmitriptan, orally disintegrating tablet – PA;
  see Table 14, p. 69
zolmitriptan, tablet – PA; see Table 14, p. 69
Zoloft # (sertraline) – see Table 17, p. 77
zolpidem 5 mg– PA > 45 units/month; see
  Table 15, p. 72
zolpidem 10 mg – PA > 30 units/month; see
  Table 15, p. 72
zolpidem, extended-release tablet – PA; see
  Table 15, p. 72
zolpidem, sublingual – PA
Zometa (zoledronic acid)
Zomig (zolmitriptan) – PA; see Table 14, p. 69
Zomig Nasal Spray (zolmitriptan) – PA; see
  Table 14, p. 69
Zomig-ZMT (zolmitriptan, orally disintegrating
  tablet) – PA; see Table 14, p. 69
Zonalon (doxepin)
Zone-A Forte (pramoxine/hydrocortisone)
Zonegran # (zonisamide) – see Table 20, p. 86
zonisamide – see Table 20, p. 86
Zorbtive (somatropin) – PA; see Table 9, p. 56
Zostavax (herpes zoster vaccine) – PA < 60
  years; see Table 32, p. 114
Zosyn (piperacillin/tazobactam)
Zovia # (ethinyl estradiol/ethynodiol)
Zovirax # (acyclovir), capsule, suspension, tablet
Zovirax (acyclovir) cream – PA
Zovirax (acyclovir) ointment – PA
Zyban # (bupropion sustained-release) – see
  Table 6, p. 51
Zydone (hydrocodone/acetaminophen) – PA;
  see Table 8, p. 55
Zyflo CR (zileuton extended-release) – PA; see
  Table 40, p. 129
Zylet (loteprednol/ tobramycin) – see Table 34,
  p. 117
Zyloprim # (allopurinol)
Zymar (gatifloxacin, ophthalmic) – PA; see
  Table 34, p. 117

May 3, 2010                                          38
Therapeutic Class and Clinical Criteria Tables

                                           MassHealth Evaluation Criteria
                                            Table 1. Immune Globulins
Drug Category: Vaccines and Immune Serums
Medication Class/Individual Agents: Immune Serums

I. Prior-Authorization Requirements
    Drug Name                                                 PA Status    Clinical Notes
    antithymocyte globulin (equine)                                        Rate and Route of Administration:
        (ATG equine, LIG) – Atgam                                             Administer only at rate, route, and
    antithymocyte globulin (rabbit)                                           concentration indicated for product; too rapid
        (ATG rabbit) – Thymoglobulin                                          IV administration rate may lead to a
    cytomegalovirus immune globulin IV, human                                 precipitous drop in blood pressure, fluid
        (CMV-IGIV) – CytoGam                                                  overload, and a possible thrombotic event.
    hepatitis B immune globulin, human                                        Cautious use in patients with history of
        (HBIG) – BayHep B, H-BIG, HyperHep, Nabi-HB                           cardiovascular disease or thrombotic
    immune globulin IM, human                                                 episodes.
        (IGIM; gamma globulin; IgG) – immune serum
        globulin USP1, BayGam                                              Renal Risk:
    immune globulin IV, human                                 PA             IGIV (human) products have been associated
        (IGIV) – Carimune, Flebogamma, Gamimune N,                           with renal dysfunction, acute renal failure,
        Gammagard S/D, Gammar-P IV, Gamunex, Iveegam                         and osmotic nephrosis. Risk factors include
        EN, Panglobulin, Polygam S/D, Sandoglobulin,                         age > 65 years, preexisting renal dysfunction,
        Venoglobulin-I, Venoglobulin-S                                       volume depletion, concurrent use of
    immune globulin, subcutaneous (Vivaglobin)                PA             nephrotoxic drugs, diabetes, and sepsis. An
                                                                             additional risk appears to be associated with
    rabies immune globulin IM, human
                                                                             IGIV products containing sucrose as a
        (RIG) – BayRab, Imogam Rabies – HT, Hyper RAB
                                                                             stabilizer (Panglobulin, Gammar-P) when a
    Rho(D) immune globulin IM
                                                                             total dose ≥ 400mg/kg was given. Note that
        (Rho(D) IGIM) – BayRho-D Full Dose, Gamulin Rh,
                                                                             RespiGam also contains sucrose.
        HypRho-D, RhoGAM
    Rho(D) immune globulin IM micro-dose                                   Hypersensitivity Reactions:
        (Rho(D) IG Micro-dose) – BayRho-D Mini Dose,                         Reportedly rare, however incidence may
        HypRho-D Mini-Dose, MICRhoGAM, Mini-Gamulin                          increase with use of large IM doses or
        Rh                                                                   repeated injections of immune globulins
    Rho(D) immune globulin IV, human
        (Rho(D) IGIV) – RhoPhylac, WinRho SDF                              Live Virus Vaccines (measles, mumps, rubella,
    tetanus immune globulin IM, human (TIG) – BayTet,                      varicella):
        Hypertet                                                              Antibodies present in immune globulin
    varicella-zoster immune globulin IM, human (VZIG)                         preparations may interfere with the immune
                                                                              response of live virus vaccines, especially
                                                                              when large doses of immunoglobulins are
                                                                              given. For many immune globulins, a live
                                                                              virus vaccine should not be administered
                                                                              within 3 months of immune globulin
                                                                              administration; a few immune globulins
                                                                              require an even longer period (5-11 months)
                                                                              before a live virus vaccine should be given;
                                                                              check individual manufacturer’s
                                                                              recommendations for each product.
1
    Product must be obtained through the Massachusetts Public Health Biologic Laboratories.




May 3, 2010                                                   39
Therapeutic Class and Clinical Criteria Tables

Table 1. Immune Globulins (cont.)

II. Therapeutic Uses
       FDA-approved, for example:
       • idiopathic thrombocytopenia purpura (ITP)
       • Kawasaki disease (mucocutaneous lymph node syndrome)
       • B-Cell chronic lymphocytic leukemia (CLL)
       • pediatric HIV type 1 infection
       • bone marrow transplant (BMT)

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

III. Evaluation Criteria for Approval
         • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
         • Additional criteria may apply, depending upon the member’s condition and requested medication (see
           below).

    Primary Immunodeficiency Disorders (Vivaglobin SC only)
        • Documentation of the following is required:
          o an appropriate diagnosis;
          o dose is appropriate for member and treatment course; and
          o clinical rationale provided for subcutaneous route of administration over IV.

    Primary immunodeficiency disorders (e.g. congenital agammaglobulinemia, severe combined immunodeficiency
    (SCID), Wiskott-Aldrich Syndrome, common variable immunodeficiency (CVID), hypogammaglobulinemia, X-
    linked agammaglobulinemia)
        • Documentation of the following is required:
          o laboratory documentation supporting diagnosis (e.g. serum IgG, IgM, and/or IgA levels); and
          o dose is appropriate for member.

    Idiopathic thrombocytopenia purpura (ITP)
        • Documentation of the following is required:
          o documentation supporting diagnosis and appropriateness for IVIG treatment (e.g. platelets < 30,000 /mm3
            and/or has clinically significant bleeding; and
          o dose is appropriate for member and treatment course.

    Kawasaki disease (mucocutaneous lymph node syndrome)
       • Documentation of the following is required:
         o documentation that the onset of illness occurred within the previous 10 days or if the member exhibits signs of
           persistent inflammation; and
         o drug and dose are appropriate for the member.

    Prevention of recurrent infection in B-cell chronic lymphocytic leukemia (CLL)
        • Documentation of the following is required:
          o documentation supporting diagnosis; and
          o dose is appropriate for member and treatment course.

    Prevention of recurrent infection in pediatric HIV type 1 infection
        • Documentation of the following is required:
          o documentation supporting diagnosis;
          o member is 18 years of age or younger;
          o CD4 count > 200 cells/μl; and
          o drug and dose are appropriate for the member.

Original Effective Date: 5/2003                                                             Last Revised Date: 5/2009



May 3, 2010                                                  40
Therapeutic Class and Clinical Criteria Tables

                                  MassHealth Evaluation Criteria
                    Table 2. Hormones – Gonadotropin-Releasing Hormone Analogs
Drug Category: Hormones
Medication Class/Individual Agents: Gonadotropin-Releasing Hormone Analogs

I. Prior-Authorization Requirements
 Drug Name                      PA Status    Clinical Notes
 degarelix (Firmagon)           PA           For PA drugs, one of the following FDA-approved indications must be
 goserelin (Zoladex)            PA           met. For unlabeled uses, approval will be considered based on current
 histrelin (Supprelin LA,       PA           medical evidence.
     Vantas)                                 • breast cancer (advanced) – Zoladex
 leuprolide (Eligard, Lupron,   PA           • central precocious puberty – Lupron, Supprelin LA, Synarel
     Viadur)                                 • endometrial thinning – Zoladex
 nafarelin (Synarel)            PA           • endometriosis – Lupron, Synarel, Zoladex
 triptorelin (Trelstar)         PA           • prostatic cancer (advanced) – degarelix, Eligard, Lupron, Trelstar,
                                                  Vantas, Viadur, Zoladex
                                             • prostatic carcinoma (Stage B2-C) – Zoladex
                                             • uterine leiomyomata – Lupron

                                             Contraindications:
                                             • pregnancy and lactation – all products
                                             • undiagnosed, abnormal vaginal bleeding: Eligard, Lupron,
                                                  Viadur, Zoladex


II. Therapeutic Uses
    FDA-approved, for example:
    • breast cancer (advanced) – Zoladex
    • central precocious puberty – Lupron, Supprelin LA, Synarel
    • endometrial thinning – Zoladex
    • endometriosis – Lupron, Synarel, Zoladex
    • prostatic cancer (advanced) – Eligard, Firmagon, Lupron, Treslstar, Vantas, Zoladex
    • uterine leiomyomata – Lupron

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see
       below).

    Endometriosis (Lupron, Synarel, Zoladex), uterine leiomyomata (Lupron), endometrial thinning prior to
    endometrial ablation (Zoladex), or advanced breast cancer (Zoladex)
    • Documentation of the following is required:
      o a diagnosis of endometriosis, symptomatic uterine leiomyomata (fibroids), the need for endometrial thinning prior
        to endometrial ablation (for dysfunctional uterine bleeding), or advanced breast cancer; and
      o the dose/frequency is appropriate for the indication provided.
    • In cases of endometriosis, prescriber must provide documentation of other interventions tried or reasons why other
      interventions are not indicated (e.g., NSAIDs and oral contraceptives).
    • With requests for Synarel, prescriber must provide a detailed explanation as to why an IM formulation cannot be
      used.

    SmartPA: Claims for Zoladex will usually process at the pharmacy without a prior authorization request if the member
    has a history of MassHealth pharmacy medical claims for breast cancer.†


May 3, 2010                                                 41
Therapeutic Class and Clinical Criteria Tables

Table 2. Hormones – Gonadotropin-Releasing Hormone Analogs (cont.)

    Idiopathic or neurogenic central precocious puberty (CPP) (Lupron, Supprelin and Synarel)
    • Documentation of the following is required:
      o a diagnosis of CPP with onset of secondary sex characteristics before age eight years (female) or nine years (males);
      o a prescriber is a pediatric endrocrinologist or documentation of a consultation with a pediatric endrocrinologist is
        provided; and
      o member is currently less than 11 years (females) or 12 years (males) of age.
    • With requests for Supprelin, prescriber must provide a detailed explanation as to why an IM formulation cannot be
      used.
    • With requests for Synarel, prescriber must provide a detailed explanation as to why an IM formulation and the
      subcutaneous implant cannot be used.

    Treatment of prostate cancer (Eligard, Firmagon, Lupron, Trelstar, Vantas and Zoladex)
    • Documentation of the following is required:
      o a diagnosis of advanced prostate cancer; and
      o the dose and frequency are appropriate for the product form chosen.

      SmartPA: Claims for Eligard, Firmagon, Lupron (7.5 mg, 11.25 mg 3 month kit, 22.5 mg 3 month kit, and Lupron 4
      month kit), Trelstar, Vantas, and Zoladex will usually process at the pharmacy without a prior authorization request if
      the member has a history of MassHealth medical claims for prostate cancer.†

Note: The decision on whether PA is required is based on 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: 5/2001                                                             Last Revised Date: 11/2009




May 3, 2010                                                  42
Therapeutic Class and Clinical Criteria Tables
                                   MassHealth Evaluation Criteria
         Table 3. Gastrointestinal Drugs – Histamine H2 Antagonists/Proton Pump Inhibitors
Drug Category: Gastrointestinal Drugs
Medication Class/Individual Agents: Histamine H2 Antagonists/Proton Pump Inhibitors

I. Prior-Authorization Requirements
 Drug Name                PA       Average     Clinical Notes
                          Status   Monthly
                                   Cost $
 cimetidine *                      $3.85-      Optimize Dosing Regimen:
    (Tagamet #)                    $13.85(#)   • For duodenal or gastric ulcer treatment, administer total daily dose between
 famotidine *                      $5.02-         evening meal and bedtime; ulcer healing is directly proportional to degree of
    (Pepcid #)                     $6.84(#)       nocturnal acid reduction.
 nizatidine (Axid ,       PA       $76.89-     Duration of Therapy:
    generic)                       $154.78     • duodenal ulcer (DU) – 4 weeks
 ranitidine capsules      PA       $16.26-     • gastric ulcer (GU) – 8 weeks
                                   $30.94
 ranitidine syrup                  $43.64
                                   (#)
 ranitidine tablets *              $3.50(#)
    (Zantac #)
 ranitidine,              PA       $100.58
    effervescent tablet
    (Zantac
    EFFERdose)

Proton Pump Inhibitors (PPIs)
 Drug Name                PA       Average     Clinical Notes
                          Status   Monthly
                                   Cost $
 dexlansoprazole          PA       $114.98     Optimize Dosing Regimen:
    (Dexilant)                                 • For maximum efficacy, a PPI must be taken in a fasting state, just before or with
 esomeprazole             PA       $157.82-       breakfast. In general for patients on PPIs, it is not necessary to prescribe other
    (Nexium, Nexium                $315.63        antisecretory agents (e.g., H2 antagonists, prostaglandins). If an antisecretory agent
    IV)                                           is prescribed with a PPI, the PPI should not be taken within 6 hours of the H2
 lansoprazole capsules    PA > 2   $314.90        antagonist or prostaglandin. PPIs should not be taken on an “as needed” basis.
    (Prevacid)            years                QD Dosing versus BID Dosing:
 lansoprazole, orally     PA > 2   $153.39     • QD dosing is adequate for most individuals except for H. pylori treatment (PPI is
    disintegrating        years                   BID for 1st two weeks of therapy). For pathological hypersecretory conditions,
    tablet (Prevacid                              such as ZE Syndrome, a BID PPI regimen may be needed for high total daily
    SoluTab)                                      doses. When/if a second dose is prescribed, it should be taken just before the
 lansoprazole             PA       $716.94        evening meal.
    (Prevacid IV)                              Apparent PPI Non-responder:
 omeprazole 20 mg,                 $14.60-     • Careful history should be obtained to ensure appropriate timing of drug
    10 mg                          $32.14         administration and no significant drug interactions (see above), before prescribing
 omeprazole 40 mg         PA       $61.74         a second dose or switching to another PPI.
 omeprazole               PA       $139.72     Duration of Therapy:
    suspension                                 • duodenal ulcer (DU) – 4 weeks (QD dosing)
    (Prilosec)                                 • gastric ulcer (GU) – 8 weeks (QD dosing)
 pantoprazole             PA       $104.10-    • H. pylori – 2 weeks (BID dosing) + 2 more weeks if DU using QD dosing and 6
    suspension, tablet             $125.93        more weeks if GU using QD dosing
    (Protonix)                                 • acute symptomatic GERD – 4-8 weeks (QD dosing)
 pantoprazole                      $378.00
    (Protonix IV)                              NG Tube Administration:
                                               Omeprazole (Rx) capsules, Prevacid (lansoprazole) capsules, and Nexium
                                               (esomeprazole) capsules may be opened and mixed in a small amount of liquid (see
                                               specific product information for further information on liquids compatible with
                                               capsule contents and the recommended techniques for NG tube administration).




May 3, 2010                                                     43
Therapeutic Class and Clinical Criteria Tables

Table 3. Gastrointestinal Drugs – Histamine H2 Antagonists/Proton Pump Inhibitors (cont.)
 Drug Name                   PA            Average       Clinical Notes
                             Status        Monthly
                                           Cost $
 rabeprazole                 PA            $164.84       Tablet/Capsule Administration:
    (Aciphex)                                            PPI tablets or the contents of PPI capsules should not be chewed, split, or crushed. For
                                                         patients who have difficulty swallowing PPI capsules, the capsule can be opened and
                                                         the intact granules can be sprinkled on applesauce. See specific product information
                                                         for further information on liquids and foods compatible with capsule contents.

Combination H. Pylori Medications
 Drug Name                   PA            Average       Clinical Notes
                             Status        Monthly
                                           Cost $
 bismuth subcitrate/         PA            $333.31       With the exception of lansoprazole, the generic ingredients of the combination
    metronidazole/                                       products do not require prior authorization. As noted above, omeprazole is the PPI that
    tetracycline                                         does not require prior authorization.
    (Pylera)
 Bismuth                     PA            $326.85
    subsalicylate/
    tetracycline/metro
    nidazole
     (Helidac)
 lansoprazole/               PA            $345.68
    amoxicillin/
    clarithromycin
    (Prevpac)
# This is 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.
* The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization.
$
  This value represents the average monthly cost of the most commonly prescribed quantities as of 7/2009. Where applicable, cost represents that of an
  “A”- rated generic equivalent (#).

II. Therapeutic Uses
    FDA-approved, for example:
    • gastroesophageal reflux disease (GERD)
    • duodenal or gastric reflux ulcer
    • GERD in children with underlying conditions, including severe chronic respiratory disease, neurologic disability, etc
    • pathological hypersecretory syndromes (e.g., Zollinger-Ellison)
    • extraesophageal symptoms/conditions secondary to gastric reflux (e.g., asthma, non-cardiac chest pain, etc)
    • non-ulcer or functional dyspepsia

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see
       below).

     Nizatadine
     • Documentation of the following is required:
       o an appropriate diagnosis; and;
       o an inadequate clinical response to at least two generic H2-antagonists that do not require prior authorization,
         prescribed at therapeutic doses for an appropriate duration; or
       o an adverse reaction to at least two generic H2-antagonists that do not require prior authorization.

     Ranitidine capsules
     • Documentation of the following is required:
       o supporting medical necessity for capsule formulation over tablets.

May 3, 2010                                                                 44
Therapeutic Class and Clinical Criteria Tables

Table 3. Gastrointestinal Drugs – Histamine H2 Antagonists/Proton Pump Inhibitors (cont.)
    Pantoprazole tablets
    • Documentation of the following is required:
      o an appropriate clinical indication; and
      o an inadequate clinical response to omeprazole at therapeutic doses for an appropriate duration; or
      o an adverse reaction to contraindication to omeprazole.

    Aciphex tablets, Dexilant capsules, Nexium capsules, and lansoprazole capsules (two years of age or older)
    • Documentation of the following is required:
      o appropriate clinical indication; and
      o an inappropriate clinical response to both omeprazole and pantoprazole at therapeutic doses for an appropriate
        duration; or
      o an adverse reaction or contraindication to both omeprazole and pantoprazole.

    Nexium suspension, Prilosec powder for suspension, and Protonix suspension
    • Documentation of the following is required:
      o appropriate clinical indication;
      o a swallowing disorder or a condition affecting swallowing ability; and
      o an inadequate clinical response to omeprazole at therapeutic doses for an appropriate duration; or
      o an adverse reaction or contraindication to omeprazole.

    Prevacid solutions
    • Documentation of the following is required:
      o an appropriate clinical indication; and
      o documentation, including medical records, with a well-defined rationale (i.e. feeding tube), explaining why the
        member cannot use conventional doseage forms (i.e., oral tablet or capsule).

      SmartPA: Claims for Prevacid solutabs for members two years of age and older will usually process at the pharmacy
      without a prior authorization request if the member has MassHealth medical claims for GERD, DU, GU, ZE
      syndrome, esophagitis, or functional dyspepsia and MassHealth medical claims for a feeding tube.†

    Prevacid IV and Nexium IV
    • Documentation of the following is required:
      o appropriate clinical indication;
      o medical necessity for intravenous route of administration; and
      o an inadequate clinical response or adverse reaction to a trial of Protonix IV.

Original Effective Date: 1/2002                                                            Last Revised Date: 2/2010




May 3, 2010                                                   45
Therapeutic Class and Clinical Criteria Tables

                                         MassHealth Evaluation Criteria
                                         Table 4. Hematopoietic Agents
Drug Category: Blood and Circulation Agents
Medication Class/Individual Agents: Hematopoietic Agents

I. Prior-Authorization Requirements
 Drug Name                      PA Status           Clinical Notes
 Colony-Stimulating Factors                         For PA drugs, an FDA-approved indication must be met. For
 Filgrastim; G-CSF (Neupogen)                       unlabeled uses, approval will be considered based on current
 pegfilgrastim (Neulasta)                           medical evidence.
 sargramostim; GM-CSF (Leukine)
 Interleukins                                       Monitoring:
 oprelvekin; IL-11 (Neumega)                        • colony-stimulating factors (G-CSF, GM-CSF) – Certain
 Recombinant Human Erythropoietin                     drugs, such as corticosteroids and lithium, may potentiate the
 darbepoetin alfa (Aranesp)     PA                    myeloproliferative effects of colony-stimulating factors;
                                                      GM-CSF: fluid retention, occasional transient
 epoetin alfa; EPO (Epogen,     PA
                                                      supraventricular arrhythmias, and dyspnea may occur. Use
    Procrit)
                                                      cautiously in patients with cardiac or pulmonary disease.

                                                    • erythropoietin – Evaluate iron status before and during
                                                      therapy. Transferrin saturation should be at least 20% and
                                                      serum ferritin at least 100 ng/ml. Most patients will
                                                      eventually require supplemental iron.

                                                    • oprelvekin – Fluid retention will occur. Use cautiously in
                                                      patients with CHF or preexisting fluid collections (e.g.,
                                                      ascites, pericardial, or pleural effusions).

II. Therapeutic Uses
    FDA-approved, for example:
    • anemia of chronic renal failure – Aranesp, Epogen, Procrit
    • anemia in zidovudine-treated HIV-infected patients – Aranesp, Epogen, Procrit
    • anemia in cancer patients on chemotherapy – Epogen, Neumega, Procrit
    • decreased need for blood transfusions in surgery patients – Epogen, Procrit
    • acute myeloid leukemia patients receiving induction or consolidation chemotherapy – Neupogen
    • cancer patients receiving bone marrow transplant – Neupogen
    • patients undergoing peripheral blood progenitor cell collection and therapy – Neupogen
    • severe chronic neutropenia – Neupogen
    • prevention of severe thrombocytopenia following myelosuppressive chemotherapy in adult patients with
      nonmyeloid malignancies – Neumega
    • shorten time to neutrophil recovery following induction chemotherapy in older adult patients with acute
      myelogenous leukemia – Leukine
    • to decrease the incidence of infection in patients with non-myeloid malignancies receiving myelosuppressive
      anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia – Neulasta

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see
       below).

    Anemia due to chronic renal failure
    • Documentation of the following is required:
      o HCT < 30% or HgB < 10 g/dL; and
      o GFR < 30 ml/min; or
May 3, 2010                                                 46
Therapeutic Class and Clinical Criteria Tables

Table 4. Hematopoietic Agents (cont.)
       o GFR 30-60 ml/min and other causes of anemia have been ruled out (iron, vitamin B12, folate deficiency and
          hemolysis).

    Anemia due to cancer chemotherapy
    • Documentation of the following is required:
      o HCT < 30% or HgB < 10 g/dL; and
      o member is on chemotherapy.

    Anemia due to HIV-zidovudine treatment
    • Documentation of the following is required:
      o HCT < 30% or HgB < 10 g/dL; and
      o member is on myelosuppressive medication for the treatment of HIV.

         SmartPA: Claims for Aranesp, Epogen, and Procrit will usually process at the pharmacy without a prior
         authorization request if the member has a history of MassHealth pharmacy claims for peginterfereon and/or
         ribavirin in the last 45 days.†

†
 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: 9/2003                                                     Last Revised Date: 5/2009




May 3, 2010                                                      47
Therapeutic Class and Clinical Criteria Tables

                                       MassHealth Evaluation Criteria
                                  Table 5. Anti-TNF and Antipsoriatic Agents
Drug Category: Pain and Inflammation, Dermatological Agents
Medication Class/Individual Agents: Anti-TNF Agents, Antipsoriatic Agents

I. Prior-Authorization Requirements
 Drug Name                                    PA Status           Clinical Notes
 Oral/Injectable                                                  For PA drugs, one of the following FDA-approved
 abatacept (Orencia)                          PA                  indications must be met. For unlabeled uses,
 adalimumab (Humira)                          PA                  approval is considered based on current medical
 alefacept (Amevive)                          PA                  evidence.
 anakinra (Kineret)                           PA
 certolizumab (Cimzia)                        PA                  Anti-TNF-alpha agents warnings and precautions:
 etanercept (Enbrel)                          PA                  • Injection site reactions, infusion reactions,
 golimumab (Simponi)                          PA                     infections, demyelinating disease, heart failure,
                                                                     malignancy, induction of autoimmunity; see
 infliximab (Remicade)                        PA
                                                                     manufacturers’ information for full details.
 rituximab (Rituxan)                          PA
 toclizumab (Actemra)                         PA                  Monoclonal antibodies warning and precautions:
 ustekinumab (Stelara)                        PA                  • History of malignancy, patients with HIV
                                                                    infection, lymphopenia, malignancy, serious
                                                                    infections, immunosuppression, allergic
                                                                    reactions, hepatic injury, immune-mediated
                                                                    thrombocytopenia or hemolytic anemia,
                                                                    psoriasis worsening and variants; see
                                                                    manufacturers’ information for full details.

II. Therapeutic Uses
    FDA-approved, for example:
    • ankylosing spondylitis – Enbrel, Humira, Remicade, Simponi
    • Crohn’s disease – Cimzia, Humira, Remicade
    • Non-Hodgkin’s lymphoma – Rituxan
    • plaque psoriasis, moderate to severe – Amevive, Enbrel, Humira, Remicade, Stelara
    • polyarticular juvenile arthritis, moderate to severe – Enbrel, Humira, Orencia
    • psoriatic arthritis – Enbrel, Humira, Remicade
    • rheumatoid arthritis, moderate to severe – Actemra, Cimzia, Enbrel, Humira, Kineret, Orencia, Remicade, Rituxan,
      Simponi
    • ulcerative colitis – Remicade

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication
       (see below).

    Rheumatoid arthritis (Actemra, Kineret)
    • Documentation of the following is required:
      o an appropriate diagnosis;
      o member is >18 years of age;
      o an inadequate response, adverse reaction, or contraindication to at least one disease-modifying anti-rheumatic
        drug (DMARD); and
      o an inadequate response, adverse reaction, or contraindication to at least one TNF-blocking agent.




May 3, 2010                                                  48
Therapeutic Class and Clinical Criteria Tables

Table 5. Anti-TNF and Antipsoriatic Agents (cont.)

    Rheumatoid arthritis (Cimzia, Enbrel, Humira, Orencia, Remicade, Simponi), juvenile rheumatoid arthritis
    (Enbrel, Humira, Orencia), psoriatic arthritis (Enbrel, Humira, Remicade), and ankylosing spondylitis (Enbrel,
    Humira, Remicade, Simponi )
    • Documentation of the following is required:
      o an appropriate diagnosis; and
      o an inadequate response or adverse reaction to at least one DMARD.

    Rheumatoid arthritis (Rituxan)
    • Documentation of the following is required:
      o an appropriate diagnosis;
      o an inadequate response or adverse reaction to at least one TNF antagonist; and
      o concurrent therapy with methotrexate; or
      o documentation of an adverse reaction or contraindication to methotrexate if requesting monotherapy.

    Non-Hodgkin’s lymphoma (Rituxan)
    • Documentation of the following is required:
      o an appropriate diagnosis.

    Plaque psoriasis (Amevive)
    • Documentation of the following is required:
      o diagnosis of moderate to severe plaque psoriasis;
      o member is >18 years of age; and
      o an inadequate response, adverse reaction, or contraindication to at least two conventional therapies in any one of
        the following combinations:
          one topical agent plus one systemic agent;
          one topical agent plus one phototherapy;
          one systemic agent plus one phototherapy; or
           two systemic agents.

Phototherapy: ultraviolet A and topical psoralens (topical PUVA), ultraviolet A and oral psoralens (systemic PUVA),
narrow band UV-B (NUVB)
Systemic Agents: methotrexate, sulfasalazine, cyclosporine, tacrolimus, acitretin, mycophenolate mofetil
Topical Agents: emollients, keratolytics, corticosteroids, coal tar, anthralin, calcipotriene, tazarotene

    Plaque psoriasis (Enbrel, Humira, Remicade, Stelara)
    • Documentation of the following is required:
      o diagnosis of moderate to severe plaque psoriasis; and
      o an inadequate response, adverse reaction, or contraindication to at least two conventional therapies in any one of
        the following combinations:
          one topical agent plus one systemic agent;
          one topical agent plus one phototherapy;
          one systemic agent plus one phototherapy; or
          two systemic agents.

Phototherapy: ultraviolet A and topical psoralens (topical PUVA), ultraviolet A and oral psoralens (systemic PUVA),
narrow band UV-B (NUVB)
Systemic Agents: methotrexate, sulfasalazine, cyclosporine, tacrolimus, acitretin, mycophenolate mofetil
Topical Agents: emollients, keratolytics, corticosteroids, coal tar, anthralin, calcipotriene, tazarotene

    Crohn’s disease (Humira, Cimzia, and Remicade)
    • Documentation of the following is required:
      o appropriate diagnosis; and
      o an inadequate response or adverse reaction to all of the following:
          aminosalicylates;
          antibiotics;
          corticosteroids; and
          immunomodulators such as azathioprine, 6-mercaptopurine or methotrexate.
May 3, 2010                                                  49
Therapeutic Class and Clinical Criteria Tables

Table 5. Anti-TNF and Antipsoriatic Agents (cont.)

    Fistulizing disease (Remicade)
    • Documentation of the following is required:
      o an appropriate diagnosis; and
      o an inadequate response or adverse reaction to immunomodulators such as azathioprine or 6-mercaptopurine.

    Ulcerative Colitis (Remicade)
    • Documentation of the following is required:
      o an appropriate diagnosis; and
      o an inadequate response or adverse reaction to all of the following:
          aminosalicylates;
           corticosteroids; and
           immunomodulators such as azathioprine, 6-mercaptopurine or cyclosporine.

Original Effective Date: 9/2003                                             Last Revised Date: 2/2010




May 3, 2010                                               50
Therapeutic Class and Clinical Criteria Tables

                                          MassHealth Evaluation Criteria
                                           Table 6. Smoking Cessation

Drug Category: Central Nervous System Agents
Medication Class/Individual Agents: Smoking Cessation

I. Prior-Authorization Requirements
 Drug Name                         PA Status                  Clinical Notes
 bupropion sustained-release                                  PA is also required for duplicate therapy with nicotine
    (Zyban #)                                                 replacement drugs and varenicline (Chantix).
 nicotine inhaler (Nicotrol)       PA                         • Treatment regimens that involve tobacco-dependence
 nicotine nasal spray (Nicotrol)   PA                            counseling have consistently demonstrated an
 nicotine gum 1                    PA > 90 days/treatment        increased efficacy of smoking cessation attempts.
                                   regimen and PA > two
                                   treatment regimens/year    Product Selection:
 nicotine lozenges (Commit)        PA > 90 days/treatment     • Nicotine gum, lozenges, and transdermal patches are
                                   regimen and PA > two         available over-the-counter (OTC).
                                   treatment regimens/year    • No nicotine delivery system is demonstrably superior
 transdermal nicotine systems 1    PA > 90 days/treatment       to another, and all appear similarly effective.
                                   regimen and PA > two
                                   treatment regimens/year    FDA Pregnancy Categories
 varenicline (Chantix)             PA > 24 weeks/year
                                                              • Category C
                                                                bupropion SR
                                                                varenicline

                                                                  • Category D
                                                                     nicotine gum
                                                                     nicotine inhaler
                                                                     nicotine lozenges
                                                                     nicotine nasal spray
                                                                     transdermal nicotine system
1
  The PA requirement applies to the generic over-the-counter and prescription versions of this drug.
# This is 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, liquid) does not have an FDA “A”-rated generic equivalent.

II. Therapeutic Uses
     FDA-approved, for example:
    • smoking-cessation assistance

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see
       below).

    Nicotine gum, lozenges, or transdermal patch for > 90 days/treatment and > two treatment regimens per year
    • Documentation of the following is required:
      o medical necessity for nicotine replacement therapy for greater than 90 days/treatment and for greater then
        two treatment regimens per year.

    Nicotine nasal spray or nicotine inhaler
    • Documentation of the following is required:
      o an inadequate response or adverse reaction to nicotine replacement therapy products that do not require



May 3, 2010                                                  51
Therapeutic Class and Clinical Criteria Tables

Table 6. Smoking Cessation (cont.)
        prior authorization; and
      o an inadequate response, adverse reaction, or contraindication to bupropion or varenicline.

    Chantix > 24 weeks/year
    • Documentation of the following is required:
      o the member has quit smoking within the previous 24 weeks of therapy;
      o the member is currently not smoking; and
      o the member requires additional therapy for sustained abstinence.

Original Effective Date: 3/2006                                                     Last Revised Date: 4/2008




May 3, 2010                                                  52
Therapeutic Class and Clinical Criteria Tables

                                         MassHealth Evaluation Criteria
                                   Table 7. Muscle Relaxants – Centrally Acting
 Drug Category: Musculoskeletal
 Medication Class/Individual Agents: Muscle Relaxants

 I. Prior-Authorization Requirements
 Drug Name                                            PA Status     Clinical Notes
  baclofen (Lioresal #, Lioresal Intrathecal)                       Precautions:
  carisoprodol (Soma)                                 PA            • All agents within this class may cause drowsiness
  carisoprodol/aspirin (Soma Compound)                PA               and dizziness. Patients should be advised of this and
  carisoprodol/aspirin/codeine (Soma                  PA               to avoid alcohol and other CNS depressants.
      Compound/Codeine)                                             • anticholinergic effects – baclofen, cyclobenzaprine,
  chlorzoxazone (Parafon Forte DSC #)                                  orphenadrine, tizanidine
  cyclobenzaprine (Fexmid)                            PA            • cyclobenzaprine – structurally related to tricyclic
  cyclobenzaprine (Flexeril #)                                         antidepressants (TCAs); consider potential for
  cyclobenzaprine extended release (Amrix)            PA               similar adverse effects and drug interactions as with
  diazepam (generics) injection, oral                                  TCAs.
      solution, tablet                                              • tizanidine – an alpha2 agonist structurally related to
  metaxalone (Skelaxin)                               PA               clonidine; may cause hypotension; hepatocellular
  methocarbamol (Robaxin #)                                            injury reported — monitor LFTs.
  orphenadrine (Norflex #)
                                                                    Urine discoloration:
  orphenadrine/aspirin/caffeine (Norgesic #)
                                                                    • orange or red-purple: chlorzoxazone
  tizanidine capsule (Zanaflex)                       PA
                                                                    • brown, black, or green: methocarbamol
  tizanidine tablet (Zanaflex #)
 # This is 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.

 II. Therapeutic Uses
      FDA-approved, for example:
      • spastic conditions
      • adjunctive treatment to rest, physical therapy, and other measures for the relief of discomforts associated with
         acute, painful musculoskeletal disorders.

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

 III. Evaluation Criteria for Approval
       • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
       • Additional criteria may apply, depending upon the member’s condition and requested medication (see
         below).

        Spastic Conditions
        Brand-name products (Dantrium, Lioresal, and Zanaflex)
        • Documentation of the following is required:
          o an inadequate response, adverse event, actual or potential contraindication, or history of pharmacy claims to
            all of the least costly alternatives (dantrolene, baclofen, and tizanidine); and
          o an adverse reaction (including medical records) to the generic product or a history of allergic reaction to an
            inactive ingredient contained in the generic product, or an inadequate response (including medical
            records) to the generic product.

        Musculoskeletal Conditions
        Brand-name products (Flexeril, Norflex, Norgesic, Orphengesic, Parafon Forte DSC, and Robaxin)
        • Documentation of the following is required:
          o requested drug is an adjunct to rest, physical therapy, and other measures for the relief of
            discomforts associated with acute, painful musculoskeletal disorders;


May 3, 2010                                                        53
Therapeutic Class and Clinical Criteria Tables

Table 7. Muscle Relaxants – Centrally Acting (cont.)
          o an adverse reaction (including medical records) to the generic product or a history of allergic reaction to an
            inactive ingredient contained in the generic product, or an inadequate response (including medical records)
            to the generic product; and
          o an inadequate response, adverse event, actual or potential contraindication, or history of pharmacy claims
            to all of the least costly alternatives including cyclobenzaprine, orphenadrine, methocarbamol, and
            chlorzoxazone.

        Amrix, Fexmid, or Skelaxin
        • Documentation of an inadequate response, adverse event, or actual or potential contraindication to all of
          the least costly alternatives (cyclobenzaprine, orphenadrine, methocarbamol, and chlorzoxazone) is required.

        SmartPA: Claims for Skelaxin will usually process at the pharmacy without a prior-authorization request if the
        member has a history of MassHealth medical claims for a musculoskeletal disorder and MassHealth pharmacy
        claims for the following drugs within the past 13 months: cyclobenzaprine, orphenadrine, methocarbamol, and
        chlorzoxazone.†
 †
  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: 9/2005                                                          Last Revised Date: 2/2010




May 3, 2010                                                    54
Therapeutic Class and Clinical Criteria Tables

Table 8 – Narcotic Agonist Analgesics
Drug Name                                                                    PA Status                Clinical Notes
codeine                                                                 PA > 360 mg/day               Allergy:
codeine/aspirin (generics)                                                                            • True systemic narcotic allergy, such as a
codeine/acetaminophen (Tylenol/codeine #)                                                                 generalized rash, or angioedema, is unusual. A
codeine powder                                                          PA                                local, itchy wheal formation at the site of narcotic
fentanyl buccal film (Onsolis)                                          PA                                injection, generalized pruritus (no rash) or
fentanyl buccal tablet (Fentora)                                        PA                                flushing may occur, and is due to histamine
fentanyl injection                                                                                        release. Meperidine is less likely to release
                                                                                                          histamine than morphine or other phenanthrenes;
fentanyl powder                                                         PA
                                                                                                          histamine release is not associated with fentanyl
fentanyl transdermal system (Duragesic)                                 PA
                                                                                                          or methadone.
fentanyl transmucosal system (Actiq)                                    PA
hydrocodone/acetaminophen (Anexsia #, Hydrocet #,                                                     Cross-Hypersensitivity:
   Lorcet #, Lortab #, Maxidone #, Norco #, Vicodin #)                                                • Systemic allergy manifestations, such as a
hydrocodone/acetaminophen (Hycet, Liquicet, Xodol,                      PA                               generalized rash, or angioedema, although
   Zydone)                                                                                               uncommon, are most likely to occur with natural
hydrocodone/ibuprofen (Ibudone, Reprexain)                              PA                               opium alkaloids, such as morphine and codeine. If
hydrocodone/ibuprofen (Vicoprofen #)                                                                     systemic allergy to morphine or codeine, a
hydrocodone powder                                                      PA                               narcotic from a different chemical classification
hydromorphone (Dilaudid #)                                              PA > 60 mg/day                   (i.e., diphenylheptanes, phenylpiperidines) should
hydromorphone powder                                                    PA                               be selected. Ultram (tramadol) is structurally
levorphanol (Levo-Dromoran #)                                           PA > 32 mg/day                   unrelated to opiates; however, the manufacturer
levorphanol powder                                                      PA                               states that it should not be used if there is previous
meperidine (Demerol)                                                    PA                               hypersensitivity reaction to opiates.
methadone (Dolophine #, Methadose #)                                    PA > 120 mg/day
                                                                                                      Renal Dysfunction:
methadone powder                                                        PA
                                                                                                      • Accumulation of certain narcotics in patients with
morphine controlled release (MS Contin #, Oramorph SR)                  PA > 360 mg/day                  significant renal dysfunction can lead to excess
morphine extended-release (Avinza)                                      PA                               sedation, respiratory depression, delirium,
morphine injection (Astramorph PF, Duramorph,                                                            myoclonus, or seizures.
   Infumorph)                                                                                            - avoid use: meperidine
morphine oral immediate release (MS/L, MSIR, OMS,                       PA > 360 mg/day                  - cautious use: codeine, hydrocodone, morphine
   Roxanol, Roxanol-T)
morphine/naloxone (Embeda)                                              PA                            Constipation:
morphine powder                                                         PA                            • Common adverse effect with chronic narcotic use;
morphine suppositories (MS/S, RMS, Roxanol)                                                             prescribe stool softener +/- laxative with narcotic.
morphine sustained release (Kadian)                                     PA
oxycodone immediate release (Endocodone, Oxydose,                       PA >240 mg/day                Acetaminophen Hepatotoxicity:
   OxyFAST, Oxy IR, Roxicodone)                                                                       • Acetaminophen has been associated with severe
oxycodone/acetaminophen (Endocet, Roxicet, Tylox #)                                                      hepatotoxicity following acute and chronic
                                                                                                         ingestion.
oxycodone/acetaminophen (Alcet, Lynox, Magnacet,                        PA
   Percocet, Perloxx)                                                                                 • Maximum recommended dose of acetaminophen
                                                                                                         for adults is four grams/day.
oxycodone/aspirin (Endodan, Percodan #, Roxiprin)
                                                                                                      • Be sure to consider and ask about all potential
oxycodone/ibuprofen (Combunox)                                          PA
                                                                                                         sources of acetaminophen (e.g., OTC,
oxycodone powder                                                        PA
                                                                                                         combination analgesics) when determining daily
oxycodone controlled release (OxyContin)                                PA                               acetaminophen dose.
oxycodone immediate release (Dazidox)                                   PA                            • Risk may increase with concurrent alcohol use,
oxymorphone extended release tablet (Opana ER)                          PA                               underlying liver disease, and/or the fasting state.
oxymorphone injection, suppositories (Numorphan)
oxymorphone tablet (Opana)                                              PA                            Duplicate Narcotic Therapy:
propoxyphene (Darvon #)                                                                               • Standard practice in chronic pain management
propoxyphene napsylate (Darvon N)                                                                       includes a long-acting narcotic for maintenance
propoxyphene napsylate/acetaminophen                                                                    and a short-acting narcotic for break-through pain.
   (Darvocet-N #)                                                                                     • Prior authorization is required for > two long-
propoxyphene powder                                                     PA                              acting narcotics for > three months.
propoxyphene/acetaminophen (Trycet)                                     PA
sufentanil powder                                                       PA
tapentadol (Nucynta)                                                    PA
# This is 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.




May 3, 2010                                                                  55
Therapeutic Class and Clinical Criteria Tables

                                        MassHealth Evaluation Criteria
                                         Table 9. Growth Hormones
Drug Category: Endocrine and Metabolic Agents
Medication Class/Individual Agents: Pituitary Agents

I. Prior-Authorization Requirements
  Drug Name                                 PA Status    Clinical Notes
  somatropin –                              PA           Contraindications:
    Genotropin                                           • active malignancy
    Humatrope                                            • growth promotion in children with fused epiphyses
    Norditropin                                          • acute critical illness due to complications following
    Nutropin, Nutropin AQ                                   open-heart surgery or abdominal surgery
    Omnitrope                                            • acute respiratory failure
    Saizen
    Serostim                                             Warnings:
    Tev-Tropin                                           • Dosage and schedule should be individualized.
    Zorbtive                                             • Injection sites should be rotated to avoid lipoatrophy.

II. Therapeutic Uses
    FDA-approved, for example:
    • growth failure in children due to lack of endogenous growth hormone secretion – Genotropin, Humatrope,
      Norditropin, Nutropin, Nutropin AQ, Omnitrope, Saizen, Tev-Tropin
    • growth failure in children due to Prader-Willi Syndrome – Genotropin
    • growth failure in children associated with chronic renal insufficiency – Nutropin, Nutropin AQ
    • short stature associated with Turner Syndrome – Genotropin, Humatrope, Norditropin, Nutropin, Nutropin AQ
    • growth hormone deficiency in adults – Genotropin, Humatrope, Norditropin, Nutropin, Nutropin AQ,
      Omnitrope, Saizen
    • AIDS wasting or cachexia – Serostim
    • short-bowel syndrome in patients receiving specialized nutritional support – Zorbtive

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see
       below).

    Pediatric-Growth failure due to lack of endogenous growth hormone (GH) secretion
    • Documentation of the following is required:
      o results of tests documenting GH deficiency;
      o etiology of GH deficiency; and
      o evidence of growth retardation.

    Pediatric-Hypoglycemia due to growth hormone deficiency
    • Documentation of the following is required:
      o results of tests documenting GH deficiency; and
      o clinical documentation of hypoglycemia.

    Pediatric-Prader-Willi or Turner or Noonan Syndrome
    • Documentation of the following is required:
      o results of genetic testing; and
      o evidence of growth retardation.




May 3, 2010                                                56
Therapeutic Class and Clinical Criteria Tables

Table 9. Growth Hormones (cont.)
    Pediatric-Growth deficiency due to chronic renal failure
    • Documentation of the following is required:
      o clinical diagnosis of chronic renal failure;
      o etiology of chronic renal failure; and
      o evidence of growth retardation.

    Pediatric-Small for gestational age (SGA)/Intrauterine growth retardation (IUGR) and catch-up growth not
    achieved by age two
    • Documentation of the following is required:
      o diagnosis of SGA with failure to exhibit catch-up growth in first two years of life; and
      o evidence of growth retardation.

    Adult-Complicated GH deficiency
    • Documentation of the following is required:
      o tests documenting GH deficiency;
      o complication from GH deficiency;
      o evidence of periodic monitoring; and
      o intended duration of therapy.

    AIDS-associated wasting or cachexia
    • Documentation of the following is required:
      o clinical diagnosis of AIDS with continuing antiretroviral therapy;
      o evidence of wasting, including weight and BMI;
      o exclusion of other causes of weight loss; and
      o results of a trial(s) of an FDA-approved appetite stimulant.

    Short-bowel syndrome (SBS)
    • Documentation of the following is required:
      o clinical diagnosis of SBS; and
      o intended duration of therapy.

Original Effective Date: 9/2005                                                    Last Revised Date: 2/2010




May 3, 2010                                                  57
Therapeutic Class and Clinical Criteria Tables

                                      MassHealth Evaluation Criteria
                            Table 10. Dermatologic Agents – Acne and Rosacea.
Drug Category: Dermatological Agents
Medication Class/Individual Agents: Anti-acne and Rosacea Agents

I. Prior-Authorization Requirements
 Drug Name                                  PA Status   Clinical Notes
  Antibiotics (Topical)                                 Prior Authorizations:
  clindamycin 1% G, L, S (Cleocin T #)      PA > 21     • Acne–brand name and combination topical acne
                                            years          products require prior authorization, as well as
 clindamycin 1% G, (Clindagel); P           PA             convenience delivery systems (e.g., pads). Prior
    (Cleocin T); F (Evoclin)                               authorization is also required for generic topical acne
 erythromycin 2% G, O, S                    PA > 21        products for members > 21 years of age.
                                            years       • Retinoids–For PA drugs, one of the FDA-approved
 erythromycin 2% P, O (Akne-Mycin); P       PA             indications must be met. For unlabeled uses,
   (Ery 2% Pads)                                           approval will be considered based on current medical
 metronidazole 0.75% C (MetroCream #),                     evidence.
   L (MetroLotion #)
 metronidazole 0.75% G (MetroGel), 1%       PA          Benzoyl Peroxide Products:
   C (Noritate)                                         • Often used alone for noninflammatory, mainly
 sulfacetamide 10% L (Klaron #)             PA > 21       comedonal acne (Type 1).
                                            years       • Used as an adjunctive therapy for mild-moderate
 Antibiotics (Oral)                                       inflammatory acne (Type 2) with a retinoid.
 doxycycline (Adoxa, Oracea)                PA          • Part of a three-drug regimen (plus retinoid and
 minocycline extended release (Solodyn)     PA            topical antibiotic) for moderate-severe acne (Type 3).
 tetracycline, doxycycline, minocycline,                • Demonstrates antibacterial activity and some
    erythromycin, trimethoprim-                           comedolytic activity.
    sulfamethoxazole                                    • A trial of two to three months is usually required to
 Benzoyl Peroxide Agents                                  establish efficacy or treatment failure of any topical
                                                          product.
 benzoyl peroxide (generics)1 2.5% G, W;    PA > 21
    3% W; 4% L; 5% G, L, W; 8% L; 9%        years       • High incidence of local irritation is evident with most
    W; 10% G, L, W                                        topical treatments.
 benzoyl peroxide 4% G, W (Brevoxyl), P     PA
                                                        Azelaic Acid Products:
    (Inova); 8% G, W (Brevoxyl), P
    (Inova)                                             • Only Azelex approved for mild-moderate
                                                           inflammatory acne (Type 2).
 benzoyl peroxide 2.5% G, W; 5% G, W;       PA
    10% G, W (Benzac AC, Benzac W,                      • Exhibits antimicrobial activity and has comedolytic
    Desquam)                                               properties
 benzoyl peroxide 3.5% C; 5.5% C; 7%        PA          • Finacea is approved for rosacea only.
    W; 8.5% C (NeoBenz Micro)
                                                        Topical Antibiotics:
 benzoyl peroxide 3% G, P, W; 6% G, P,      PA
    W; 9% L, P, W (Triaz)                               • Used in moderate-severe acne (Types 2 and 3) as part
                                                          of a combination therapy.
 benzoyl peroxide 4.5% C, G, P, W;          PA
    5.75% W; 6.5% C, G, P, W; 8.5% C,                   • Also possesses anti-inflammatory activity.
    G, P, W (ZoDerm)                                    • Long-term use is discouraged due to increased
 benzoyl peroxide 5.3% F (Benzefoam)        PA            emergence of P acnes resistance.
 Combination Products                                   • Combination therapy with another topical medication
                                                          decreases resistance emergence.
 benzoyl peroxide/adapalene (Epiduo)        PA
                                                        • Metronidazole is approved for rosacea only.
 benzoyl peroxide/erythromycin G            PA
    (Benzamycin)                                        • Sulfacetamide products are used for mild
                                                          inflammatory acne and are highly odorous and easily
 benzoyl peroxide/clindamycin G             PA
                                                          stain. These products are contraindicated in
    (BenzaClin, Duac)
                                                          sulfonamide allergic patients.
 benzoyl peroxide/sulfur L (NuOx,           PA
    Sulfoxyl)
 benzoyl peroxide/salicylic acid P (Inova   PA
    4/1, Inova 8/2)
May 3, 2010                                             58
Therapeutic Class and Clinical Criteria Tables

Table 10. Dermatological Agents–Acne and Rosacea (cont.)
 Drug Name                                  PA Status  Clinical Notes
 clindamycin/benzoyl peroxide G             PA
    (Acanya)
 sulfacetamide/sulfur L (Plexion, Sulfacet- PA
    R), F (Clarifoam EF)
 Retinoids (Topical)
 adapalene (Differin) 0.1% C, G; 0.3% G     PA
 alitretinoin (Panretin) 0.1% G             PA
 tazarotene (Tazorac) 0.05% C, G; 0.1%      PA
    C, G
 clindamycin/tretinoin (Ziana)              PA
 tretinoin; trans-retinoic acid; vitamin A  PA > 21
    acid 0.01% G; 0.025% C, G; 0.05% C, years
    S; 0.1% C (Avita#, Retin-A #)
 tretinoin microsphere gel (Retin-A Micro) PA
    0.04%, 0.1% G
 Retinoids (Oral)
 acitretin (Soriatane)
 isotretinoin; 13-cis-Retinoic Acid         PA > 21
     (Accutane #, Amnesteem, Claravis,      years
     Sotret)
 tretinoin
 Miscellaneous Agents
 azelaic acid 20% C (Azelex); 15% G         PA
     (Finacea)
 dapsone G (Aczone)                         PA
C=cream; E=emulsion; F=foam; G=gel; L=lotion; O=ointment; P=pads; S=solution; W=wash

# This is 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.
1
    The PA requirement applies to the generic over-the-counter and prescription versions of this drug.
2
    Indicated for acute promyelocytic leukemia.
II. Therapeutic Uses
    FDA-approved, for example:
    • Acne vulgaris – Azelex, Avita, benzoyl peroxide, clindamycin, Differin, erythromycin, sulfacetamide, Retin-A,
      Tazorac, tretinoin
    • Kaposi’s sarcoma cutaneous lesions - Panretin
    • Nodulocystic acne (severe), Recalcitrant - Accutane
    • Promyelocytic leukemia - Vesanoid
    • Psoriasis (stable) – Tazorac, Soriatane
    • Rosacea – Finacea, metronidazole
      Note: The above list may not include all FDA-approved indications.
III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see
       below).
      Acne
      Members > 21 years of age for all products
      • Documentation of the following is required:
        o appropriate diagnosis; and
        o medical necessity for anti-acne product.

May 3, 2010                                                    59
Therapeutic Class and Clinical Criteria Tables

Table 10. Dermatological Agents–Acne and Rosacea (cont.)
    Brand-name topical products for all ages (excluding retinoids)
    • Documentation of the following is required:
      o adverse reaction or inadequate response to at least two clinically appropriate generic anti-acne products with the
        same active ingredient.

    Brandname oral antibiotics (Adoxa, Solodyn)
    • Documentation of the following is required:
      o adverse reaction to clinically appropriate generic products or rationale why they cannot be used.

    Unique dosage forms for all ages (i.e., pads, pledgets)
    • Documentation of all of the following is required:
      o adverse reaction or inadequate response to at least two clinically appropriate generic anti-acne products with the
        same active ingredient; and
      o medical necessity for a specific dosage form.

    Combination products for all ages
    • Documentation of the following is required:
      o compelling rationale that the combination product would offer a therapeutic advantage over the commercially
        available separate agents.

    Brand-name topical retinoids for all ages (Differin, Retin-A, Tazorac)
    • Documentation of one of the following is required:
      o adverse reaction or inadequate response to generic tretinoin; or
      o psoriasis (tazarotene only).

    Oral retinoids for members > 21 years (isotretinoin)
    • Documentation of the following is required:
      o inadequate response to a topical retinoid used in combination with benzoyl peroxide and/or topical/oral antibiotics;
        or
      o documentation of moderate to severe acne.

    Rosacea
    Brand-name topical products
    • Documentation of the following is required:
      o adverse reaction or inadequate response to at least two clinically appropriate generic products with the same active
        ingredient.

    Generic benzoyl peroxide products and generic topical antibiotics in members > 21 years of age
    • Documentation of the following is required:
      o diagnosis of rosacea.

    Brand-name oral antibiotics (Oracea)
    • Documentation of the following is required:
      o adverse reaction to all generic doxycycline products or rationale why they cannot be used.

Original Effective Date: 9/2005                                                             Last Revised Date: 2/2010




May 3, 2010                                                  60
Therapeutic Class and Clinical Criteria Tables

                                           MassHealth Evaluation Criteria
                                   Table 11. Nonsteroidal Anti-inflammatory Drugs
Drug Category: Pain and inflammation
Medication Class/Individual Agent: Nonsteroidal Anti-Inflammatory Drugs (NSAIDS)
I. Prior-Authorization Requirements
A. Non-Selective NSAIDs
 Drug Name                                                    PA Status                      Clinical Notes
 Acetic Acid Derivatives                                                                     Risk factors for NSAID-related GI toxicity:
 etodolac extended-release                                    PA                             • age > 60 years, history of gastric or
 etodolac (Lodine #)                                                                            duodenal ulcer, history of GI bleed,
 indomethacin extended-release                                PA                                perforation or obstruction, concurrent
 indomethacin (Indocin #)                                                                       use of anticoagulants, aspirin (including
 nabumetone (Relafen #)                                                                         low doses for cardiovascular
 sulindac (Clinoril #)                                                                          prophylaxis), corticosteroids, high daily
 tolmetin (Tolectin #)                                                                          NSAID doses
 Anthranilic Acid Derivatives                                                                To avoid or minimize GI toxicity:
 meclofenamate                                                                               • Lowest effective dose should be
 mefenamic acid (Ponstel)                                     PA                                prescribed for the shortest possible
 Enolic Acid Derivatives                                                                        duration.
 meloxicam                                                                                   • GI toxicity may be lower with
 meloxicam (Mobic #)                                          PA < 60 years                     ibuprofen, naproxen, ketoprofen,
 piroxicam (Feldene #)                                                                          diclofenac, and higher with
 Phenylacetic Acid Derivatives                                                                  indomethacin, flurbiprofen, and
 diclofenac (Cataflam #, Voltaren # )                                                           piroxicam.
 diclofenac (Zipsor )                                         PA
                                                                                             If risk factors are present for NSAID-
 diclofenac extended-release (Voltaren XR #)                  PA
                                                                                                  related GI toxicity as above, consider:
 diclofenac/misoprostol (Arthrotec)                           PA < 60 years
                                                                                             • etodolac, nabumetone and meloxicam,
 diclofenac topical gel (Solaraze)                            PA
                                                                                                  all of which are preferential COX-2
 diclofenac topical gel (Voltaren gel)                        PA                                  inhibitors; however, with higher doses
 diclofenac topical patch (Flector patch)                     PA                                  of etodolac and nabumetone,
 Propionic Acid Derivatives                                                                       preferential inhibition of COX-2 is
 fenoprofen 600 mg                                                                                diminished
 fenoprofen (Nalfon) 200 mg, 400 mg                           PA                             • highly selective COX-2 inhibitor (see
 flurbiprofen (Ansaid #)                                                                          table below).
 ibuprofen * (Motrin #)                                                                      • an antisecretory agent (PPI or
 ibuprofen injection H (Caldolor)                                                                 misoprostol) with a non-selective
 ketoprofen                                                                                       NSAID
 ketoprofen extended-release                                  PA
 ketorolac (Toradol #)                                        PA > 20 units/month            Risk factors for NSAID-related renal
 naproxen * (Anaprox #, Naprosyn #)                                                          toxicity:
 naproxen controlled-release 375 mg and 500 mg                PA                             • preexisting renal disease, severe CHF,
     (Naprelan CR)                                                                               liver disease, or diuretic use
 naproxen controlled-release 750 mg (Naprelan CR)             PA
 naproxen extended-release                                    PA
 oxaprozin (Daypro #)
 Salicylic Acid Derivative
 diflunisal (Dolobid #)
B. COX-2 (Highly Selective) NSAIDs
 Drug Name                                                    PA Status                      Clinical Notes
 celecoxib (Celebrex)                                         PA < 60 years                  Osteoarthritis (OA)/Rheumatoid Arthritis
                                                                                             (RA) Dosing:
                                                                                             • Celebrex: OA: 200 mg QD or 100 mg
                                                                                                 BID; RA: 100-200 mg BID
                                                                                             Sulfonamide Allergy:
                                                                                             • Celebrex is a sulfonamide derivative. The
                                                                                                labeling for Celebrex states that use is
                                                                                                contraindicated in sulfonamide-allergic
                                                                                                patients.
# This is 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.
* The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization.

May 3, 2010                                                                 61
Therapeutic Class and Clinical Criteria Tables

Table 11. Nonsteroidal Anti-inflammatory Drugs (cont.)
II. Therapeutic Uses
    FDA-approved, for example:
    • acute pain
    • mild-to-moderate pain
    • osteoarthritis
    • primary dysmenorrhea
    • rheumatoid arthritis
    • juvenile rheumatoid arthritis – celecoxib and meloxicam only
    • familial adenomatous polyposis (FAP) – celecoxib only
    • ankylosing spondylitis – celecoxib only

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply depending upon diagnosis or requested medication (see below).

    Brand-name nonselective NSAIDs and mefenamic acid (See Table A.)
    • Documentation of a clinically significant adverse event to at least two generic, nonselective NSAIDs is
      required. If appropriate, at least one of the two trial drugs must include the AB-rated generic of the
      requested brand-name product.

    Ketorolac >20 units/month
    • Documentation of trials with all other less costly, safer alternatives (i.e., generic nonselective NSAIDs) is
      required.

    Celebrex, meloxicam, and Mobic for < 60 years old
    • Documentation of the following is required:
      o risk for a clinically significant gastrointestinal event or history of a gastrointestinal event; and
      o a clinically significant adverse event or inadequate response to at least two generic nonselective
        NSAIDs.

         SmartPA: Claims for Celebrex will usually process at the pharmacy without a prior-authorization request
         if the member has a history of MassHealth medical claims for an appropriate diagnosis (see therapeutic uses)
        and:
      o a history of MassHealth pharmacy claims for at least two different generic NSAIDs; or
      o a history of pharmacy claims for warfarin, antiplatelet drug, or oral corticosteroid in the last 30 days. †

    Brand-name Mobic
    • Documentation, including medical records, of a clinically significant reaction to the generic equivalent or to
      its inactive ingredients is required.

    Meloxicam suspension
    • Documentation of the following is required:
      o medical necessity for the suspension formulation; and
      o risk for a clinically significant gastrointestinal event or history of a gastrointestinal event or a
        clinically significant adverse event or inadequate response to nonselective NSAIDs.

    Controlled-release and extended-release NSAIDs
    • Documentation of the following is required:
      o appropriate diagnosis; and
      o medical necessity for an extended-release formulation over the immediate release equivalent.

    Arthrotec for members < 60 years
    • Documentation of the following is required:
      o medical necessity for the combination product; and
      o risk for a clinically significant gastrointestinal event or history of a gastrointestinal event or a
        clinically significant adverse event or inadequate response to nonselective NSAIDs.
May 3, 2010                                                     62
Therapeutic Class and Clinical Criteria Tables

Table 11. Nonsteroidal Anti-inflammatory Drugs (cont.)

       Flector topical patch
       • Documentation of the following is required:
         o acute pain caused by minor strains, sprains, and contusions;
         o a daily dose of not more than two patches/day; and
         o documentation of medical necessity for a transdermal formulation; or
         o documentation of an inadequate clinical response, adverse reaction, or contraindication to a generic diclofenac
           product and at least one additional generic NSAID.

       Solaraze
       • Documentation of the following is required:
         o Actinic Keratosis; and
         o documentation of inadequate response to topical fluororacil and imiquimod.

       Voltaren Gel
       • Documentation of the following is required:
         o osteoarthritis; and
         o documentation of medical necessity for a topical formulation or a clinically adverse event or inadequate
           response to acetaminophen and at least two different generic nonselective NSAIDS.

       Zipsor
       • Documentation of the following is required:
         o mild to moderate pain; and
         o documentation of inadequate response to generic diclofenac and at least one different generic nonselective
           NSAID.
†
    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: 9/2002                                                                    Last Revised Date: 2/2010




May 3, 2010                                                        63
Therapeutic Class and Clinical Criteria Tables

                                                 MassHealth Evaluation Criteria
                                                   Table 12. Antihistamines
Drug Category: Cough/Cold/Allergy
Medication Class/Individual Agent: Antihistamines

I. Prior-Authorization Requirements:
   First Generation (Nonselective) Antihistamines
    Drug                                                  PA                      Sedative              Antihistamine         Anticholinergic
    Name 1                                                Status                  Effect 2              Effect 2              Effect 2
    Alkylamines
    brompheniramine *                                                             1+                    3+                    2+
    chlorpheniramine * (Chlor-Trimeton #)                                         1+                    2+                    2+
    chlorpheniramine (QDall AR)                           PA                      1+                    2+                    2+
    chlorpheniramine/pseudoephedrine
       (QDall)                                            PA
    Ethanolamines
    carbinoxamine (Palgic)                                PA                      1+                    1+/2+                 1+
    clemastine (Tavist #)                                                         2+                    1+/2+                 3+
    diphenhydramine * (Benadryl #)                                                3+                    1+/2+                 3+
    Phenothiazine
    promethazine (Phenergan #)                                                    3+                    3+                    3+
    Piperazines
    hydroxyzine (Atarax #, Vistaril #)                                            3+                    2+/3+                 2+
    Piperidines
    cyproheptadine (Periactin #)                                                  1+                    2+                    2+

     Second Generation (Peripherally Selective) Antihistamines
    Drug                                           PA                             Sedative              Antihistamine         Anticholinergic
    Name 1                                         Status                         Effect 2              Effect 2              Effect 2
    Alkylamine
    acrivastine/pseudoephedrine (Semprex-D)        PA                             +/-                   2+/3+                 +/-
    Nasal Preparations
    azelastine (Astelin, Astepro)                  PA                             +/-                   2+/3+                 +/-
    olopatadine (Patanase)                         PA
    Piperazines
    cetirizine syrup, tablet (generics)
    levocetirizine (Xyzal)                         PA                             +/-                   2+/3+                 +/-
    Piperidines
    desloratadine (Clarinex)                       PA                             +/-                   3+                    +/-
    desloratadine/pseudoephedrine                  PA
       (Clarinex-D)
    fexofenadine (Allegra)                         PA                             +/-                   2+/3+                 +/-
    fexofenadine orally disintegrating tablet      PA
        (Allegra ODT)
    fexofenadine/pseudoephedrine (Allegra-D)       PA
    loratadine (generics)                                                         +/-                   2+/3+                 +/-
# This is 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.
* The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization.
1
    Combinations of antihistamines and decongestants (for example, brompheniramine/pseudoephedrine) are payable under MassHealth, but are not
    listed in the antihistamine table unless PA is required for the combination.
2
    low to none = +/-; low = 1+; moderate = 2+; high = 3+ (Note: Pseudoephedrine, a sympathomimetic that may cause mild CNS stimulation, may
    lessen the sedative effect of antihistamines. Occasionally however, pseudoephedrine may also cause drowsiness. The antihistaminic and
    anticholinergic effects of antihistamines are not likely to be affected by the addition of pseudoephedrine.)




May 3, 2010                                                                  64
Therapeutic Class and Clinical Criteria Tables

Table 12. Antihistamines (cont.)
II. Therapeutic Uses
    FDA-Approved, for example:
    • perennial or seasonal allergic rhinitis
    • chronic idiopathic urticaria

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose and frequency.
     • Additional criteria may apply depending upon requested medication (see below).

    Clarinex, fexofenadine, and Xyzal
    • Documentation of one of the following is required:
      o an adverse reaction that is not class specific to loratadine and cetirizine; or
      o an inadequate clinical response to loratadine and cetirizine prescribed at therapeutic doses for an adequate
        duration.

    Allegra suspension, Clarinex syrup, and Xyzal solution
    • Documentation of a swallowing disorder and one of the following is required:
      o contraindication to loratadine and cetirizine;
      o an adverse reaction to loratadine and cetirizine that is not class specific; or
      o an inadequate clinical response to loratadine and cetirizine prescribed at therapeutic doses for an adequate
        duration.

    Brand-name selective antihistamines (Allegra)
    • Documentation of the following is required:
      o an inadequate clinical response to loratadine and cetirizine prescribed at therapeutic doses for an adequate
        duration or an adverse reaction or a contraindication that is not class specific to loratadine and cetirizine; and
      o an inadequate response (including medical records) or adverse reaction (including medical records) to the A-
        rated generic fexofenadine tablet or a history of an allergic reaction to the inactive ingredients used in the
        manufacturing process of a certain product or an inadequate response (including medical records) during a
        clinical trial with the A-rated generic fexofenadine tablet.

    Brand-name non-selective antihistamines
    • Documentation of one of the following is required:
      o an adverse reaction (not class specific) to at least two generic nonselective antihistamines from different
        chemical subclasses. If appropriate, at least one trial must include an A-rated generic equivalent
        of the requested brand-name nonselective antihistamine, or
      o an inadequate response to at least two generic nonselective antihistamines from different chemical
        subclasses prescribed at therapeutic doses for an appropriate period of time. If appropriate, at least one
        trial must include an A-rated generic equivalent of the requested brand-name nonselective antihistamine.

    Astelin nasal spray, Astepro nasal spray, and Patanase nasal spray
    • Documentation of one of the following is required:
      o an inadequate response or adverse reaction to at least two second generation antihistamines; or
      o medical necessity for a topical formulation.
    • For quantities greater than 1 inhaler/month, in addition to the above criteria, documentation must be provided
      regarding an inadequate clinical response to Astelin/Patanase at the manufacturer’s recommended doses.

Original Effective Date: 6/2003                                          Last Revised Date: 5/2009




May 3, 2010                                                    65
Therapeutic Class and Clinical Criteria Tables

                                                     MassHealth Evaluation Criteria
                                                     Table 13. Lipid-Lowering Agents
Drug Category: Cardiovascular
Medication Class/Individual Agent: Lipid-Lowering Agents
I. Prior-Authorization Requirements
    Drug Name                                PA Status               Average Monthly Price$    Clinical Notes
    Bile Acid Sequestrants                                                                     The NCEP ATP III guidelines can be found on the
    cholestyramine                                                   $78.60(#)                 following Web site:
      (Prevalite #, Questran #)                                                                www.nhlbi.nih.gov/guidelines/cholesterol.
    colestipol (Colestid #)                                          $31.89(#)
    colesevelam (Welchol), tablet            PA (effective           $206.01                   Statins: All statins are subject to a quantity limit of
                                             5/17/10)                                          30 units/month.
    colesevelam (Welchol), powder            PA                      $207.00
       for suspension                                                                          Adverse Effects
    Cholesterol Absorption Inhibitors                                                          • Hepatotoxicity
    ezetimibe (Zetia)               PA                               $101.64                     Although the risk of liver toxicity is low, the
    ezetimibe/simvastatin           PA                               $96.69-$102.98              risk may increase with dose increments. Liver
       (Vytorin)                                                                                 function tests should be performed
    Fibric Acids                                                                                    o before the drug is prescribed;
    fenofibrate (Antara, Fenoglide, PA                               $21.96-$61.88                  o at 8 or 12 weeks following therapy
       Lipofen, Tricor, Triglide)                                                                        initiation;
    fenofibrate (Lofibra #)                                          $21.96-$61.88(#)               o at 8 or 12 weeks following an increase in
                                                                                                         dose; and
    fenofibric acid (Fibricor,      PA                               $108.49
                                                                                                    o semiannually.
       Trilpix)
    gemfibrozil (Lopid #)                                            $9.02(#)
                                                                                               • Myopathy
    HMG-CoA Reductase Inhibitors1
    atorvastatin (Lipitor)          PA                               $84.29-$120.24              Severe dose-related myopathy has been
                                                                                                 reported. It can lead to myoglobinuria and acute
    amlodipine/atorvastatin                  PA                      $150.49 (all strengths)     renal failure. Risk factors for statin-induced
       (Caduet)                                                                                  myopathy are drug-drug interactions, hepatic or
    fluvastatin (Lescol)                     PA                      $78.97 (all strengths)      renal failure, acute infection, or
    fluvastatin extended-release             PA                      $101.43                     hypothyroidism.
       (Lescol XL)
    lovastatin (Mevacor #)                   PA > 30                 $9.98-$14.83(#)           • Fenofibrate
                                             units/month                                         Dose conversion is necessary when switching
    lovastatin extended-release              PA                      $154.98-$180.18             between micronized and nonmicronized
      (Altoprev)                                                                                 formulations. A dose conversion table is listed
    pravastatin (Pravachol #)                PA > 30                 $8.50-$16.96(#)             below.
                                             units/month
    rosuvastatin (Crestor)                   PA                      $107.58 (all strengths)    Nonmicronized             Micronized
    simvastatin (Zocor #)                    PA > 30                 $5.29-$7.04(#)             fenofibrate               fenofibrate
                                             units/month                                        48 mg                     67 mg
    Nicotinic Acids                                                                             145 mg                    200 mg
    niacin*                                                          $3.00                     McEvoy GK, Eds. American Hospital Formulary
    niacinamide*                                                     $0.60-$1.80               Services, AHFS Drug Information. The American
    niacin, extended-release                                         $89.62-$128.66            Hospital Formulary Service. Bethesda. 2007.
       tablet (Niaspan)
    niacin, extended-release/                PA                      $90.00                    • Nicotinic Acids – niacin for lipid lowering
        lovastatin (Advicor)                                                                     OTC nicotinic acid products are classified as
    niacin, extended                         PA                      $62.09-$111.10              dietary supplements by the FDA and should not
       release/simvastatin (Simcor)                                                              be used as a substitute for prescription niacin
    nicotinic acid*                                                  $3.00                       for lipid lowering.
    Miscellaneous products
    omega-3-acid ethyl esters                PA                      $152.97
       (Lovaza)
# This is a bralnd-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.
* The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization.
$
   This value represents the average monthly cost of the most commonly prescribed quantities as of 7/2009. Where applicable, cost represents that of an
   “A” - rated generic equivalent (#).
1
    All statins are subject to a quantity limit of 30 units/month.


May 3, 2010                                                                          66
Therapeutic Class and Clinical Criteria Tables
Table 13. Lipid-Lowering Agents (cont.)

II. Therapeutic Uses

    Fibric Acids
    FDA-approved, for example:
    • hypertriglyceridemia
    • hypercholesterolemia
    • mixed dyslipidemias

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

    Ezetimide (Zetia)
    FDA- approved, for example:
    • primary hyperlipidemia (as monotherapy or in combination with a statin)
    • mixed hyperlipidemia (in combination with fenofibrate)
    • homozygous sitosterolemia
    • homozygous familial hypercholesterolemia

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

    Statins
    FDA-approved, for example:
    • hypertriglyceridemia
    • mixed hyperlipidemia
    • primary hyperlipidemia
    • primary and secondary progression of coronary heart disease

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

    Miscellaneous Products – Lovaza
    FDA-approved, for example:
    • hypertriglyceridemia

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

III. Evaluation Criteria for Approval

    Colesevelam (Welchol) for the Treatment of Hypercholesterolemia
    • All prior-authorization requests must include clinical diagnosis, drug name, dose and frequency.
    • Documentation of the following is required:
      o age > 18 years; and
      o an adverse reaction or inadequate response to statin therapy; and
      o an adverse reaction or inadequate response to cholestyramine or colestipol; or
      o age > 18 years; and
      o an adverse reaction or inadequate response to cholestyramine or statin therapy.

    Fibric Acids
    • All prior-authorization requests must include clinical diagnosis, drug name, dose and frequency.
    • Documentation of the following is required:
      o failure of an adequate trial of a therapeutically equivalent formulation; and
      o compelling rationale (medical necessity) why brand-name fenofibrate would offer a therapeutic advantage
        over the therapeutically equivalent fenofibrate formulations.

    Ezetimide (Zetia)
    • Documentation of all of the following is required:
      o clinical diagnosis, drug name, dose, and frequency;
      o a daily dose of not more than 10 mg/day; and

May 3, 2010                                                   67
Therapeutic Class and Clinical Criteria Tables

Table 13. Lipid-Lowering Agents (cont.)
      o an inadequate response to (> 40 mg/day simvastatin or an equipotent dose of another statin) for a
        therapeutically appropriate time period or an adverse reaction or contraindication to a statin.

    Statins
    • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
    • Additional criteria may apply depending upon requested medication (see four subcategories below).

      (1) All agents if > 30 units/month
      o Documentation of rationale why dose consolidation is not possible is required.

      (2) Altoprev, Crestor, Lescol, Lescol XL, Lipitor, and Vytorin
      o Documentation of one of the following is required:
           an inadequate response to (≥ 40 mg/day simvastatin) for a therapeutically appropriate time period; or
           adverse reaction (not class specific), or contraindication to simvastatin (see special considerations below).

      (3) Special considerations for organ transplant/HIV
      o Requests for nonreference statins will be considered for members receiving medications that may result in
        drug interactions.

      (4) Combination products (Advicor, Caduet, Simcor)
      o Documentation of one of the following is required:
          treatment with stable doses of the separate agents for a minimum of three months; or
          stabilized for at least three months on the combination product.

    Miscellaneous Products – Lovaza
    • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
    • Documentation of an adverse reaction or inadequate response to niacin and a fibric acid derivative (i.e.,
      fenofibrate or gemfibrozil) is required.

Original Effective Date: 10/2002                                                             Last Revised Date: 2/2010




May 3, 2010                                                   68
Therapeutic Class and Clinical Criteria Tables

                                       MassHealth Evaluation Criteria
                                            Table 14. Triptans

Drug Category: Pain and Inflammation
Medication Class/Individual Agent: Headache Therapy/Serotonin (5HT-1) receptor agonists

I. Prior-Authorization Requirements
  Drug Name                       PA Status                Clinical Notes
  almotriptan (Axert) tablet      PA                       Contraindications:
  eletriptan (Relpax) tablet      PA                       • history, presence, symptoms, or signs of ischemic
  frovatriptan (Frova) tablet     PA                          heart disease (e.g., angina, MI, stroke, TIA),
  naratriptan (Amerge) tablet     PA                          coronary artery vasospasm, or other significant
  rizatriptan (Maxalt-MLT),       PA                          underlying cardiovascular disease
     orally disintegrating tablet                          • uncontrolled hypertension
  rizatriptan (Maxalt) tablet     PA                       • concurrent use or use within 24 hours of
  sumatriptan (Imitrex),          PA                          ergotamine-containing products or ergot-type
     injection                                                medications (e.g., dihydroergotamine,
  sumatriptan (Imitrex), nasal    PA                          methysergide)
     spray                                                 • concurrent use with MAO inhibitor therapy or
  sumatriptan (Imitrex #), tablet PA > 9 units/month          within two weeks of MAO inhibitor
  sumatriptan/naproxen            PA                          discontinuation
     (Treximet)                                            • use within 24 hours of treatment with another
  zolmitriptan (Zomig), nasal     PA                          triptan
     spray                                                 • management of hemiplegic or basilar migraine
  zolmitriptan, (Zomig-ZMT)       PA                       • hypersensitivity to the product or any of its
     orally disintegrating tablet                             ingredients
  zolmitriptan (Zomig) tablet     PA
                                                           Do not exceed the maximum recommended dose per
                                                           24-hour period.

                                                           Orally Disintegrating Tablets:
                                                           • Place tablet on tongue, where it will be dissolved
                                                             and swallowed with saliva.
                                                           • Inform phenylketonurics that tablets contain
                                                             phenylalanine.

                                                           Migraine prophylaxis (e.g., amitriptyline, propranolol,
                                                           timolol) may be considered for the following
                                                           conditions:
                                                           • migraine occurs ≥ twice monthly and produces
                                                              disability lasting ≥ three days per month
                                                           • contraindication to, or failure of, acute treatments
                                                           • abortive medications are used > twice per week
                                                           • other severe migraine conditions

II. Therapeutic Uses
    FDA-Approved, for example:
    • acute treatment of migraine (all triptans)
    • acute treatment of cluster headache episodes-Imitrex injection only
    • triptans are NOT intended for prophylactic therapy of migraines

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




May 3, 2010                                                  69
Therapeutic Class and Clinical Criteria Tables

Table 14. Triptans (cont.)

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see
       below).

    Sumatriptan tablets (> 9 units/month)
    • Requests will be evaluated on a case-by-case basis taking into account the member’s headache frequency and
      prophylactic regimen.

    Amerge (</= 9 units/month), Axert (</= 9 units/month), Frova (</= 9 units/month), Maxalt (</= 9
    units/month), Relpax (</= 9 units/month), or Zomig (</= 9 units/month)
    • Documentation of one of the following is required:
      o an adverse reaction, which is not class specific to sumatriptan; or
      o prescriber provides documentation of an inadequate clinical response to sumatriptan.

    Amerge (> 9 units/month), Axert (> 9 units/month), Frova (> 9 units/month), Maxalt (> 9 units/month), or
    Relpax (> 9 units/month), or Zomig (> 9 units/month)
    • Documentation of one of the following is required:
      o an adverse reaction, which is not class specific to sumatriptan; or
      o prescriber provides documentation of an inadequate clinical response to sumatriptan.
    • Requests will be evaluated on a case-by-case basis taking into account the member’s headache frequency and
      prophylactic regimen.

    Maxalt-MLT and Zomig-ZMT
    • Documentation is required, including medical records, with a well-defined clinical rationale explaining why the
      member cannot use conventional dosage forms (i.e., oral tablets).

    Sumatriptan nasal spray (</= 8 units/month) and a sumatriptan injection (</= 8 units/month)
    • Documentation is required, including medical records, with a well-defined clinical rationale explaining why the
      member cannot use conventional dosage forms (i.e., oral tablet or capsule).

    Sumatriptan nasal spray (> 8 units/month) and a sumatriptan injection (> 8 units/month)
    • Documentation is required, including medical records, with a well-defined clinical rationale explaining why the
      member cannot use conventional dosage forms (i.e., oral tablet or capsule).
    • Requests will be evaluated on a case-by-case basis taking into account the member’s headache frequency and
      prophylactic regimen.

    Treximet (</= 9 units/month)
    • Documentation of the following is required:
      o compelling rationale (medical necessity) explaining why the combination product would offer a therapeutic
        advantage over the commercially available separate agents.

    Treximet (> 9 units/month)
    • Documentation of the following is required:
      o compelling rationale (medical necessity) explaining why the combination product would offer a therapeutic
        advantage over the commercially available separate agents.
    • Requests will be evaluated on a case-by-case basis taking into account the member’s headache frequency and
      prophylactic regimen.

    Zomig nasal spray (</= 8 units/month)
    • Documentation of one of the following is required:
      o an adverse reaction, which is not class specific to sumatriptan; or
      o prescriber provides documentation of an inadequate clinical response to sumatriptan.
    • Documentation is required, including medical records, with a well-defined clinical rationale explaining why the
      member cannot use conventional dosage forms (i.e., oral tablets).

May 3, 2010                                                 70
Therapeutic Class and Clinical Criteria Tables

Table 14. Triptans (cont.)
    Zomig nasal spray (> 8 units/month)
    • Documentation of one of the following is required:
      o an adverse reaction, which is not class specific to sumatriptan; or
      o prescriber provides documentation of an inadequate clinical response to sumatriptan.
    • Documentation is required, including medical records, with a well-defined clinical rationale explaining why the
      member cannot use conventional dosage forms (i.e., oral tablets).
    • Requests will be evaluated on a case-by-case basis taking into account the member’s headache frequency and
      prophylactic regimen.

Original Effective Date: 3/2002                                                            Last Revised Date: 2/2010




May 3, 2010                                                 71
Therapeutic Class and Clinical Criteria Tables

                                             MassHealth Evaluation Criteria
                                                 Table 15. Hypnotics

Drug Category: Central Nervous System (CNS)
Medication Class/Individual Agent: Hypnotics

I. Prior-Authorization Requirements
  Drug                  PA         Duration of                Average           Clinical
 Name                   Status     Action                     Monthly           Notes
                                                              Cost $
 estazolam                   PA > 30         intermediate     $5.53-            • Nonpharmacologic treatments, such as
                             units/                           $13.50 (#)          practicing good sleep hygiene, relaxation
                             month                                                training, and cognitive therapy may be more
 eszopiclone                 PA              short            $159.94-            effective than medications in some
    (Lunesta)                                                 $175.77             individuals. See “10 Tips for a Good Night’s
 flurazepam                  PA > 30         long             $3.54-$4.12         Sleep” (www.mass.gov/druglist).
    (Dalmane #)              units/                                             • There is limited medical evidence on the
                             month                                                safety and efficacy of prolonged use of
 quazepam (Doral)            PA              long             $115.92             hypnotics.
 ramelteon (Rozerem)         PA              short            $125.78           • To avoid tolerance and dependence, use the
 temazepam                   PA > 30         intermediate     $3.95-$4.75         lowest dose, intermittently, and for the
     (Restoril #, 15 mg,     units/                           (#)                 shortest possible duration.
     30 mg)                  month                                              • Recommended hypnotic dosages are
 temazepam (Restoril         PA              intermediate     $439.37             generally lower in the elderly.
     7.5 mg, 22.5 mg)                                                           • There is increasing unlabeled use of low dose
 triazolam                   PA > 30         short            $9.49-              Seroquel (<200mg/day) in the treatment of
                             units/                           $10.26              insomnia. The effects of quetiapine on weight
                             month                                                gain and metabolism are not dose related and
 zaleplon (Sonata #)         PA > 30         ultra-short      $20.20 (#)          can occur at low doses.1 Due to the lack of
                             units/                                               efficacy and safety of Seroquel in the
                             month                                                treatment of insomnia, and the increasing
 zolpidem 5 mg               PA > 45         short            $3.11 (#)           costs of the atypical antipsychotics, please
    (Ambien #)               units/                                               consider the use of alternative hypnotics
                             month                                                before prescribing Seroquel. For additional
 zolpidem 10 mg              PA > 30         short            $2.83 (#)           information please see the Seroquel letter-
    (Ambien #)               units/                                               (January 2010 Update)
                             month                                                (http://www.mass.gov/Eeohhs2/docs/masshe
 zolpidem, extended-         PA              intermediate     $156.86             alth/pharmacy/seroquel-letter_01-10.pdf.
                                                                                 1
    release tablet                                                                Simon V, van Winkel R, De Hert M. Are weight
    (Ambien CR)                                                                  gain and metabolic side effects of atypical
 zolpidem, sublingual        PA              intermediate     $126.00            antipsychotics dose dependent? A literature review. J
    (Edluar)                                                                     Clin Psychiatry 2009;70(7):1041-1050.
# This is 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.
$
  This value represents the average monthly cost of the most commonly prescribed quantities as of 12/2009. Where
  applicable, cost represents that of an “A”-rated generic equivalent (#).

II. Therapeutic Uses
    FDA-approved, for example:
    • acute insomnia
    • chronic insomnia

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




May 3, 2010                                                          72
Therapeutic Class and Clinical Criteria Tables

Table 15. Hypnotics (cont.)
III. Evaluation Criteria for Approval
     • Documentation of the following is required:
       o all prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency;
       o medical records documenting treatment plan and nonpharmacological therapies/counseling (for example, sleep
          habits/sleep hygiene); and
       o member’s current medications.
     • Additional criteria may apply depending upon diagnosis and/or requested medication (see below).

    Ambien CR, Lunesta, Rozerem
    • Documentation of the following is required:
      o an inadequate response, adverse reaction, or contraindication to at least two of the following:
          benzodiazepines;
           trazodone;
           tricyclic antidepressants (TCAs);
           mirtazapine; and
      o an inadequate response, adverse reaction, or contraindication to zolpidem.

    Doral, Restoril 7.5 mg, and temazepam 22.5 mg
    • Documentation of all of the following is required:
      o an adverse reaction, inadequate response, or contraindication to other conventional hypnotics, for example:
           trazodone; or
           tricyclic antidepressants (TCAs); or
           mirtazapine; and
      o an adverse reaction, inadequate response, or contraindication to at least four generic hypnotic benzodiazepines
         (for example, estazolam, flurazepam, temazepam, triazolam) when prescribed at therapeutic doses for an
         adequate duration.

    Edluar
    • Documentation is required, including medical records, with a well-defined clinical rationale explaining why the
      member cannot use conventional dosage forms.

    Estazolam, flurazepam, temazepam, triazolam, zaleplon, zolpidem 10 mg: quantities > 30 units/month and
    zolpidem 5: quantities > 45 units/month
    • Documentation of all of the following is required:
      o prescriber provides documentation that the dose requested cannot be consolidated; and
      o prescriber provides documentation of clinical rational for high dose requested.

Original Effective Date: 3/2005                                                     Last Revised Date: 03/2010




May 3, 2010                                                   73
Therapeutic Class and Clinical Criteria Tables

                                    MassHealth Evaluation Criteria
                                    Table 16. Topical Corticosteroids

Drug Category: Dermatological
Medication Class/Individual Agent: Corticosteroids

I. Prior-Authorization Requirements
Drug Name                               PA Status    Clinical Notes
I. Low Potency                                       Product Potency:
alclometasone dipropionate 0.05% C,                  • Relative potency of a product depends on the
   O (Aclovate #)                                       characteristics and concentration of the drug
desonide 0.05% C, L, O (DesOwen #)                      and the vehicle.
desonide 0.05% A (Verdeso); G           PA           • Generally, ointments and gels are more potent
   (Desonate)                                           than creams or lotions; however, some products
fluocinolone acetonide 0.01% C, S                       have been formulated to yield comparable
   (Synalar #)                                          potency.
fluocinolone acetonide 0.01% oil        PA
   (Derma-Smoothe/FS), shampoo                       Product Selection:
   (Capex)                                           • Selection of a specific corticosteroid, strength,
hydrocortisone 0.5% C, L; 1% C, L,                      and vehicle depends on the nature, location, and
   O, S; 2.5% C, L, O (Anusol-HC #,                     extent of the skin condition, patient’s age, and
   Hytone #, Texacort #)                                anticipated duration of treatment.
hydrocortisone acetate 2% G             PA           • Use the least potent corticosteroid that would
   (NuZon)                                              be effective.
hydrocortisone 2% aloe vera (Nucort)    PA           • Low potency agents are preferred for the face,
hydrocortisone 2% salicylic acid/sulfur PA              intertriginous areas (e.g., groin, axilla), large
   (Coraz)                                              areas, and children, to reduce the potential for
II. Medium Potency                                      side effects.
betamethasone valerate 0.12% A          PA           • Reserve higher potency agents for areas and
   (Luxiq)                                              conditions resistant to treatment with milder
betamethasone valerate 0.1% C, L                        agents.
   (Beta-Val #, Valisone #)
clocortolone pivalate 0.1% C            PA           Adverse Reactions:
   (Cloderm)                                         • Systemic absorption of topical corticosteroids
desoximetasone 0.05% C (Topicort                       has produced reversible HPA axis suppression,
   LP #)                                               Cushing’s syndrome, hyperglycemia, and
fluocinolone acetonide 0.025% C, O                     glycosuria.
   (Synalar #); 0.01% Oil (DermOtic)                 • Conditions that augment systemic absorption
flurandrenolide 0.025% C, O; 0.05%      PA             include application of more potent steroids, use
   C, L, O, T (Cordran)                                over large surface areas, prolonged use,
fluticasone propionate 0.05% C, L;      PA             addition of occlusive dressings, and patient’s
   0.005% O (Cutivate)                                 age.
fluticasone propionate 0.05% C,                      • Perform appropriate clinical and laboratory
   0.005% O (generics)                                 tests if a topical corticosteroid is used for long
hydrocortisone butyrate 0.1% C, O, S                   periods or over large areas of the body.
   (Locoid #)
hydrocortisone probutate 0.1% C         PA            With chronic conditions, gradual discontinuation
   (Pandel)                                           of therapy may reduce the chance of rebound.
hydrocortisone valerate 0.2% C, O
   (Westcort #)
mometasone furoate 0.1% C, L, O
   (Elocon #)
prednicarbate 0.1% C , O (Dermatop #)




May 3, 2010                                               74
Therapeutic Class and Clinical Criteria Tables

Table 16. Topical Corticosteroids (cont.)

Drug Name                              PA Status              Clinical Notes
triamcinolone acetonide 0.025% C,
    L, O; 0.1% C, L, O; (Aristocort #,
    Aristocort A #, Kenalog #)
triamcinolone 0.1% C (Zytopic)         PA
III. High Potency
amcinonide 0.1% C, L, O (Cyclocort #)
augmented betamethasone, 0.05% L
    (Diprolene #)
augmented betamethasone, 0.05% C
    (Diprolene AF #)
betamethasone dipropionate 0.05%
    C, G, L, O (generics)
betamethasone valerate 0.1% O
    (Beta-Val #, Valisone #)
desoximetasone 0.05% G; 0.25% C,
    O (Topicort #)
diflorasone diacetate 0.05% C
    (Psorcon #)
fluocinonide 0.05% C, G, O, S
    (Lidex #)
fluocinonide 0.1% C (Vanos)            PA
halcinonide 0.1% C, O, S (Halog,       PA
    Halog-E)
triamcinolone acetonide 0.5% C, O
   (Aristocort #, Aristocort A #,
   Kenalog # )
IV. Very High Potency
augmented betamethasone
   dipropionate 0.05% O (Diprolene #)
clobetasol propionate 0.05% C, G, O, S
   (Cormax #, Embeline #, Temovate #)
clobetasol propionate 0.05% A          PA
    (Olux), L, shampoo, spray (Clobex)
diflorasone diacetate 0.05% O
    (Psorcon #)
halobetasol propionate 0.05% C,O
    (Ultravate #)
VI. Combination Products
lidocaine 3% - hydrocortisone acetate  PA
   0.5% C (AnaMantle HC, LidaMantle
   HC), L (LidaMantle HC, Xyralid), G
   (AnaMantle HC, RectaGel)
A=aerosol, C=cream, G=gel, L=lotion, O=ointment, S=solution
# This is 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




May 3, 2010                                                         75
Therapeutic Class and Clinical Criteria Tables

Table 16. Topical Corticosteroids (cont.)

II. Therapeutic Uses
    FDA-approved, for example:
    • dermatological condition involving inflammation

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon requested medication (see below).

    Brand-name topical corticosteroid used in a scalp-related condition (Capex, Luxiq)
    • Documentation of all of the following is required:
      o a scalp-related clinical diagnosis; and
      o a clinically significant adverse event or inadequate response to one similar generic topical
        corticosteroid.

    Brand-name topical corticosteroid used for hemorrhoids (Anamantle, Lidamantle, Rectagel)
    • Documentation of all of the following is required:
      o hemorrhoids; and
      o a clinically significant adverse event or inadequate response to all generic hemorrhoidal products not requiring
        prior authorization.

      SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has a
      history of MassHealth pharmacy claims for generic hydrocortisone (see Section I).†

    Brand-name topical corticosteroids with no A-rated generics
    • Documentation of one or more of the following is required:
      o a clinically significant adverse event or inadequate response to all similar generic topical corticosteroids of the
        same potency and dosage form; or
      o a contraindication that supports the need for a specific product or dosage form of a non-reference topical
        corticosteroid.

      SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has a
      history of MassHealth pharmacy claims for generic corticosteroids of the same potency (see Section I).†

    Clobetasol foam
    • Documentation of all of the following is required:
      o a scalp-related clinical diagnosis; and
      o a clinically significant adverse event or inadequate response to one similar least costly generic topical
        corticosteroid.
†
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: 10/2002                                                              Last Revised Date: 2/2009




May 3, 2010                                                    76
Therapeutic Class and Clinical Criteria Tables

                                    MassHealth Evaluation Criteria
                                      Table 17. Antidepressants

Drug Category: Central Nervous System (CNS)
Medication Class/Individual Agent: Antidepressants

I. Prior-Authorization Requirements
  Drug Name                              PA Status   Clinical Notes
  Selective Serotonin Reuptake Inhibitors (SSRI)     • In general, the elderly are more sensitive to side
  citalopram (Celexa # )                               effects of medications especially to sedation,
  escitalopram (Lexapro)                 PA            orthostatic hypotension, and anticholinergic
  fluoxetine (fluoxetine 20 mg capsule,                symptoms. Because of changes in drug
      fluoxetine 10 mg, Prozac #)                      metabolism, older patients need lower doses of
  fluoxetine (fluoxetine 20 mg tablet,   PA            antidepressants to reach therapeutic effect. Thus
      fluoxetine 40 mg capsule, Prozac                 the maxim, “Start low and go slow.”
      Weekly, Sarafem )
  fluvoxamine (Luvox #)                              • MassHealth does not encourage the use of
  fluvoxamine extended-release (Luvox    PA            combination products and recommends that the
      CR)                                              active medications be prescribed individually.
  paroxetine hydrochloride (Paxil #)
  paroxetine mesylate (Pexeva)           PA          • There is no evidence to support the use of two
  paroxetine HCL controlled-release      PA            SSRIs or an SSRI and SNRI concurrently.
      (Paxil CR)                                       These combinations duplicate drug action, with
  sertraline (Zoloft # )                               increased side effects and little clinical benefit.
  Norepinephrine/Dopamine Reuptake Inhibitors          PA is required when a patient has an overlap of
  (NDRI)                                               60 days or more in prescriptions of two SSRIs
  bupropion (Wellbutrin #)                             or an SNRI. 1
  bupropion extended-release (Aplenzin, PA
      generics, Wellbutrin XL)                       • Due to bupropion’s dose-dependant risk of
  bupropion sustained-release                          seizure (0.33-0.4% within recommended dosing
      (Wellbutrin SR #)                                limits) please dose accordingly. Bupropion
  Serotonin Antagonist/Reuptake Inhibitors (SARI)      immediate release (IR) should be dosed no
                                                       greater than 150 mg per dose and 450 mg per
  nefazodone
                                                       day. Bupropion sustained release (SR) should be
  trazodone
                                                       dosed no greater than 200 mg per dose and 400
  trazadone 300 mg tablet                PA
                                                       mg per day. Bupropion extended-release (XL)
  Serotonin/Norepinephrine Reuptake Inhibitors         requires PA. It should be dosed no greater than
  (SNRI)                                               450 mg a day as a single dose. Patients with
  desvenlafaxine (Pristiq)               PA            seizure disorders, brain injuries, and eating
  duloxetine (Cymbalta)                  PA            disorders are at highest risk of seizures.
  venlafaxine (Effexor #)
  venlafaxine extended-release capsule   PA          • Brand-name Serzone is no longer available due
     (Effexor XR)                                      to reports of life-threatening hepatic failure
  venlafaxine extended-release tablet                  resulting in death or transplant. Generic
  Monoamine Oxidase Inhibitors (MAOI)                  nefazodone is still available from various
  phenelzine (Nardil)                                  manufacturers.
  selegiline transdermal system          PA
     (EMSAM)                                         • Blood pressure should be monitored during
  tranylcypromine (Parnate #)                          venlafaxine therapy because it may cause a
  Noradrenergic and Specific Serotonergic              dose-related increase in diastolic blood pressure
  Antidepressants (NaSSA)                              (reported in 3-13% of patients).
  mirtazapine (Remeron #)




May 3, 2010                                              77
Therapeutic Class and Clinical Criteria Tables

Table 17. Antidepressants (cont.)

 Drug Name                                 PA Status            Clinical Notes
 mirtazapine, orally disintegrating tablet PA                   • Antidepressant discontinuation syndrome has
    (generics, Remeron Sol Tab)                                    been commonly reported with SSRIs and SNRI.
 Tricyclic Antidepressants (TCA)                                   Among the SSRIs, this is most commonly
 amitriptyline                                                     reported with paroxetine (whose half-life is
 amoxapine                                                         short and there is no active metabolite), and
 clomipramine (Anafranil #)                                        reported least with fluoxetine (with a long half-
 desipramine (Norpramin #)                                         life and an active, long-acting metabolite).
 doxepin (Sinequan #)                                              Symptoms include dizziness, nausea, fatigue,
 imipramine (Tofranil #)                                           lethargy, flu-like symptoms, anxiety,
 maprotiline                                                       irritability, and insomnia. This often occurs
 nortriptyline (Aventyl #, Pamelor #)                              one-three days after abruptly stopping the
 protriptyline (Vivactil #)                                        medication. The agents in question should be
 trimipramine (Surmontil #)                                        slowly tapered to avoid this syndrome.
 Selective Serotonin Reuptake Inhibitor and
                                                                Monoamine Oxidase Inhibitors (MAOI):
 Atypical Antipsychotic
                                                                • Hypertensive crisis may occur when MAOI
 fluoxetine/olanzepine (Symbyax)           PA
                                                                  inhibitors are coadministered with some
                                                                  prescription and over-the-counter products and
                                                                  foods, especially those high in tyramine.
                                                                • Serotonin syndrome can occur when MAOI are
                                                                  coadministered with other pro-serotonergic
                                                                  medications.
                                                                • Members should be counseled about dietary
                                                                  and medication restrictions and be given a list
                                                                  of food and drugs to be avoided.
# This is 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.
1
  Prior authorization is required for more than a 60-day overlap in prescriptions in any dosage form of SSRIs, SNRIs, or SSRI and
   SNRI corresponding to duplicate therapy.

II. Therapeutic Uses
    FDA-approved, for example:
    • depressive disorders
    • anxiety disorders

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply depending upon diagnosis and/or requested medication (see below).

     Cymbalta for psychiatric indications
     • Documentation of an adverse reaction or inadequate response to less costly alternatives including one SSRI and
       one other antidepressant (for example, another SSRI, TCAs, bupropion, SARIs (nefazodone, trazodone, etc.),
       mirtazapine, venlafaxine, MAOIs, etc.) is required.

       SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has a
       history of MassHealth pharmacy claims for at least 90 days in the past 120 days of the respective medication, or
       if the member has a history of MassHealth medical claims for an appropriate diagnosis and a history of
       MassHealth pharmacy claims for an SSRI and another antidepressant (see Section I). †




May 3, 2010                                                         78
Therapeutic Class and Clinical Criteria Tables

Table 17. Antidepressants (cont.)

   Cymbalta for diabetic neuropathic pain
   • Documentation of the following is required:
     o an adverse reaction, inadequate response, or contraindication, to a tricyclic antidepressant (TCA);
       and
     o an adverse reaction, inadequate response, or contraindication to gabapentin.

   Cymbalta for fibromyalagia
   • Documentation of the following is required:
     o an adverse reaction, inadequate response, or contraindication, to two of the following: a tricyclic
       antidepressant (TCA), cyclobenzaprine, an SSRI;
     o an adverse reaction, inadequate response, or contraindication to gabapentin; and
     o an adverse reaction, inadequate response, or contraindication to milnacipran.

   Effexor XR for psychiatric indications
   • Documentation of the following is required:
     o medical records regarding an adverse reaction or inadequate response to venlafaxine extended-release tablets;
       and
     o adverse reaction or inadequate response to at least one other antidepressant such as another SSRI, TCA,
       bupropion, nefazodone, trazodone, mirtazapine, duloxetine, MAOIs, etc.

   Lexapro
   • Documentation is required, including medical records, of an adverse reaction or inadequate response to a less
     costly alternative including citalopram and one other SSRI.

     SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has a
     history of MassHealth pharmacy claims for at least 90 days in the past 120 days of the respective medication, or
     if the member has a history of MassHealth medical claims for an appropriate diagnosis and a history of
     MassHealth pharmacy claims for citalopram and another SSRI (see Section I).†

   Luvox CR, paroxetine controlled-release or bupropion extended-release
   • Documentation is required, including medical records, with a well-defined clinical rationale explaining why the
     member requires the controlled or extended-release formulation supported by evidence-based medicine.

   Generic fluoxetine 40-mg capsule and 20-mg tablet or trazodone 300-mg tablet
   • Documentation is required, including medical records, with a well-defined clinical rationale explaining why the
     member cannot use a less costly formulation of the medication which does not require prior authorization.

   EMSAM
   • Documentation of all of the following is required:
     o member is >18 years of age;
     o medical records regarding an adverse reaction or inadequate response to less costly alternatives such as an
        SSRI, SNRI, TCA, and bupropion; and
     o clinical rationale explaining why the member cannot use conventional dosage forms (i.e., oral tablet or
        capsule).
   • a daily dose of no more than 12 mg/day and/or a quantity no greater than 1 patch/day.

   Pristiq
   • Documentation of all of the following is required:
     o member is > 18 years of age;
     o medical records regarding an adverse reaction or inadequate response to less costly alternatives including a
       SSRI and another antidepressant (e.g., another SSRI, TCA, bupropion, nefazodone, trazodone, mirtazapine,
       duloxetine); and
     o medical records regarding an inadequate response to venlafaxine or venlafaxine extended-release.
   SSRIs, SNRIs >60-day overlap (therapeutic duplication)
   • Documentation is required, including medical records, with a well-defined clinical rationale explaining medical
     necessity for two SSRIs, two SNRIs, or an SSRI and SNRI concurrently.

May 3, 2010                                                  79
Therapeutic Class and Clinical Criteria Tables

Table 17. Antidepressants (cont.)
       Remeron SolTab and mirtazapine orally disintegrating tablets
       • Documentation is required, including medical records, with a well-defined clinical rationale explaining why the
         member cannot use conventional dosage forms (i.e., oral tablet or capsule).

       Prozac Weekly
       • Documentation is required, including medical records, with a well-defined clinical rationale explaining why the
         member cannot use the less costly alternative (i.e., daily generic fluoxetine).

       Sarafem
       • Documentation is required, including medical records, with a well-defined clinical rationale explaining why the
         member cannot use the less costly alternatives, which includes generic SSRIs and oral contraceptives.

       Pexeva
       • Documentation is required, including medical records, with a well-defined clinical rationale explaining why the
         member cannot use the less costly alternatives (i.e., paroxetine HCL).

       Symbyax
       • Documentation is required, including medical records, with a well-defined clinical rationale explaining why the
         member cannot use the less costly, commercially available separate agents.

       Brand-name antidepressants with A-rated generics
       • Documentation, including medical records of one of the following is required:
         o a clinically significant allergic response or adverse event to the generic product or its inactive ingredients; or
         o a clinically significant inadequate response to the generic product.
†
    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: 4/2003                                                                   Last Revised Date: 2/2010




May 3, 2010                                                       80
Therapeutic Class and Clinical Criteria Tables

                                  MassHealth Evaluation Criteria
                         Table 18. Renin Angiotensin System Antagonists

 Drug Category: Cardiovascular
 Medication Class/Individual Agent: Renin Angiotensin System Antagonists

 I. Prior-Authorization Requirements
  Drug Name                                 PA Status         Clinical Notes
   Angiotensin – Converting Enzyme (ACE) Inhibitors           Dose and administration:
   amlodipine/benazepril (Lotrel)           PA                • Initial doses may need to be lower in the
   benazepril (Lotensin #)                                       elderly, and in patients who are on a diuretic
   benazepil/hydrochlorothiazide                                 or are volume depleted.
      (Lotensin HCT #)
   captopril (Capoten #)                                      Nonproductive dry cough:
   captopril/hydrochlorothiazide                              • Incidence is about 10-20% on an ACE
      (Capozide #)                                              inhibitor, but very uncommon in the
   enalapril (Vasotec #)                                        angiotensin II receptor antagonists.
   enalapril/hydrochlorothiazide                              • Cough usually resolves within one-four days
      (Vaseretic #)                                             after therapy is discontinued.
   fosinopril (Monopril #)
   fosinopril/hydrochlorothiazide                             Adverse reactions:
      (Monopril HCT #)                                        • Higher incidence of skin rash and dysgeusia
   lisinopril (Prinivil #, Zestril #)                           with captopril, compared to other ACE
   lisinopril/hydrochlorothiazide                               inhibitors, has been attributed to its sulfhydryl
      (Prinzide #, Zestoretic #)                                group.
   moexipril (Univasc #)                                      • Risk factors for hyperkalemia may include
   moexipril/hydrochlorothiazide                                renal insufficiency, diabetes, concomitant
      (Uniretic #)                                              nonsteroidal anti-inflammatory drugs,
   perindopril (Aceon)                      PA                  potassium supplements, and/or potassium-
   quinapril (Accupril #)                                       sparing diuretics.
   quinapril/hydrochlorothiazide                              • Angioneurotic edema is less likely to occur
      (Accuretic #)                                             with angiotensin II receptor blockers than
   ramipril capsule (Altace #)                                  ACE inhibitors, but cross-reactivity has been
   ramipril tablet (Altace )                PA                  reported.
   trandolapril (Mavik #)
                                                              Pregnancy:
   trandolapril/verapamil (Tarka)           PA
                                                              • May cause fetal or neonatal injury or death
   Angiotensin II Receptor Antagonists (ARBS)
                                                                 when used during the second or third trimester
   amlodipine/olmesartan (Azor)             PA
                                                                 of pregnancy.
   amlodipine/telmisartan (Twynsta)         PA
                                                              • When pregnancy is detected, discontinue these
   amlodipine/valsartan (Exforge)           PA
                                                                 drugs as soon as possible.
   amlodipine/valsartan/hydrochlorothiazide PA
      (Exforge HCT)
   candesartan (Atacand)                    PA
   candesartan/hydrochlorothiazide          PA
      (Atacand HCT)
   eprosartan (Teveten)                     PA
   eprosartan/hydrochlorothiazide           PA
      (Teveten HCT)
   irbesartan (Avapro)                      PA
   irbesartan/hydrochlorothiazide           PA
      (Avalide)
   losartan (Cozaar)                        PA
   losartan/hydrochlorothiazide             PA
      (Hyzaar)



May 3, 2010                                             81
Therapeutic Class and Clinical Criteria Tables

Table 18. Renin Angiotensin System Antagonists (cont.)

   Drug Name                                  PA Status                  Clinical Notes
   olmesartan (Benicar)                       PA
   olmesartan/hydrochlorothiazide             PA
      (Benicar HCT)
   telmisartan (Micardis)                     PA
   telmisartan/hydrochlorothiazide            PA
      (Micardis HCT)
   valsartan (Diovan)                         PA
   valsartan/hydrochlorothiazide              PA
      (Diovan HCT)
   Direct Renin Inhibitors
   aliskiren (Tekturna)                       PA
   aliskiren/hydrochlorothiazide              PA
      (Tekturna HCT)
   aliskiren/valsartan (Valturna)             PA
# This is 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.

II. Therapeutic Uses
    FDA-approved, for example:
    • hypertension
    • congestive heart failure (captopril, candesartan,enalapril, fosinopril, lisinopril, quinapril, ramipril, trandolapril,
      valsartan)
    • left ventricular dysfunction (captopril, enalapril, trandolapril)
    • myocardial infarction (lisinopril, valsartan)
    • diabetic nephropathy (captopril, irbesartan, losartan)
    • cardiovascular events risk reduction (perindopril, ramipril)
    • reduction of stroke risk with left ventricular hypertrophy (losartan)

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon requested medication (see below).

    ACE inhibitors – single agents
    • Documentation of an inadequate response or adverse reaction to one generic ACE inhibitor is required.

       SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has
       pharmacy claims for a generic ACE inhibitor. †

    ARBs – Single agents
    • Documentation of one of the following is required:
      o an inadequate response, adverse reaction, or contraindication to an ACE inhibitor; or
      o diabetes with renal insufficiency.

       SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has
       pharmacy claims for a generic ACE inhibitor, or, the member has a history of MassHealth medical claims for
       diabetes with renal manifestations.†




May 3, 2010                                                         82
Therapeutic Class and Clinical Criteria Tables

Table 18. Renin Angiotensin System Antagonists (cont.)

       Direct renin inhibitors – Single agents
       • Documentation of the following is required:
        an inadequate response or adverse reaction 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.

       ACE inhibitors and ARB – Combination agents with HCTZ
       • Documentation of one of the following is required:
         o stable therapy on the separate agents for ≥ 3 months;
         o stable therapy on the combination agent for ≥ 3 months; or
         o medical necessity for one agent in patients with complex, multiple, comorbid conditions.

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

       Azor, Exforge, Lotrel, Tarka, Twynsta, Valturna
       • Documentation of one of the following is required:
         o treatment with stable doses of the separate agents for a minimum of three months;
         o stabilized for at least three months on the combination product; or
         o medical necessity for one agent in patients with complex, multiple, comorbid conditions.

       Exforge HCT
       • Documentation of one of the following is required:
         o stable therapy on the separate agents for > 3 months;
         o stable therapy on the combination agent for > 3 months; or
         o medical necessity for one agent in patients with complex, multiple, comorbid conditions.

†
    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: 4/2003                                                               Last Revised Date: 2/2010




May 3, 2010                                                    83
Therapeutic Class and Clinical Criteria Tables

                                     MassHealth Evaluation Criteria
                  Table 19. Alpha-1 Adrenergic Blockers and Alpha-Reductase Inhibitors

Drug Category: Men’s Health
Medication Class/Individual Agent: Alpha-1-Adrenergic-Receptor Antagonists (Alpha-Blockers); and Alpha-
                                  Reductase Inhibitors
I. Prior-Authorization Requirements
  Drug Name                    PA Status            Clinical Notes
  Alpha-1 Andrenergic Blockers                      FDA-approved indications:
  alfuzosin (Uroxatral)        PA                   • hypertension: doxazosin, prazosin, prazosin/polythiazide,
  doxazosin (Cardura #)                                terazosin
 doxazosin extended release    PA                   • benign prostatic hyperplasia (BPH): alfuzosin, doxazosin,
    (Cardura XL)                                       tamsulosin, terazosin
  prazosin (generics)
  prazosin/polythiazide                             Dose and administration:
    (Minizide)                                      • Doxazosin, prazosin, and terazosin: take first dose and
  silodosin (Rapaflo)          PA                      subsequent first increased dose at bedtime to minimize
  tamsulosin (Flomax)          PA                      lightheadedness and syncope.
  terazosin (Hytrin #)                              • Titrate to therapeutic maintenance doses to minimize
  Alpha-Reductase Inhibitors                           dizziness and orthostatic hypotension.
  dutasteride (Avodart)        PA                   • If therapy is discontinued or interrupted for two or more
 finasteride (Proscar)         PA                      days, reinstitute therapy cautiously.

                                                               PSA levels:
                                                               • Alpha-1 adrenergic receptor antagonists do not affect PSA
                                                                 levels.

# This is 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.

II. Therapeutic Uses
    FDA-approved, for example:
    • benign prostatic hyperplasia (BPH)
    • hypertension (doxazosin immediate release and terazosin only)

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon requested medication (see below).

     Tamsulosin and alfuzosin
     • Documentation of the following is required:
       o member is > 18 years of age; and
       o documentation of an inadequate response, adverse reaction, or contraindication to another alpha-blocker is required.

     Silodosin
     • Documentation of the following is required:
       o member is > 18 years of age; and
       o adverse reaction, inadequate response, or contraindication to another alpha-blocker;
       o adverse reaction, inadequate response, or contraindication to finasteride; and
       o quantity limit does not exceed 30 units/month (4 mg only).




May 3, 2010                                                         84
Therapeutic Class and Clinical Criteria Tables

Table 19. Alpha-1 Adrenergic Blockers and Alpha-Reductase Inhibitors (cont.)

    Finasteride and dutasteride
    • Documentation of the following is required:
      o member is > 18 years of age; and
      o adverse reaction, inadequate response, or contraindication to an alpha-blocker.

    Doxazosin extended-release
    • Documentation of the following is required:
      o member is > 18 years of age; and
      o inadequate response, adverse reaction, or contraindication to generic doxazosin immediate release; and
      o medical necessity for an extended release formulation.
†
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: 4/2003                                                           Last Revised Date: 2/2010




May 3, 2010                                                 85
Therapeutic Class and Clinical Criteria Tables

                                            MassHealth Evaluation Criteria
                                              Table 20. Anticonvulsants
 Drug Category: Central Nervous System (CNS)
 Medication Class/Individual Agent: Anticonvulsants

I. Prior-Authorization Requirements
 Drug Name                                           PA Status                  Clinical Notes
 carbamazepine                                                                  For PA drugs, one of the following FDA-
      (Carbatrol, Epitol,                                                       approved indications must be met.
      Equetro,Tegretol #)                                                       • diabetic peripheral neuropathy-pregabalin
 clonazepam (Klonopin #)                                                        • epilepsy, adjunctive therapy-gabapentin,
 clonazepam, orally disintegrating tablet            PA                            levetiracetam, pregabalin, tiagabine,
     (generics, Klonopin                                                           topiramate
    Wafers)                                                                     • postherpetic neuralgia-gabapentin,
 clorazepate (Tranxene-SD)                           PA                                   pregabalin
 clorazepate (Tranxene-T #)
 diazepam rectal gel (Diastat)                       PA > 5 kits (10            For unlabeled uses, approval will be
                                                     syringes/month)            considered based on current medical evidence.
 diazepam (generics) injection, oral solution,
     tablet                                                                     Precautions/warnings:
 diazepam powder                                     PA                         • About 25% to 30% of patients who
 divalproex (Depakote #)                                                           experience a hypersensitivity reaction to
 ethosuximide (Zarontin #)                                                         carbamazepine will experience a
 ethotoin (Peganone)                                                               hypersensitivity reaction to oxcarbazepine.
 felbamate (Felbatol)                                                           • Carbamazepine has been associated with
 gabapentin (Neurontin #)                                                          aplastic anemia and agranulocytosis.
 gabapentin powder                                   PA > 18 years                 Hematologic studies should be performed
 lacosamide injection (Vimpat)                                                     before therapy is initiated.
 lacosamide tablet (Vimpat)                          PA                         • Felbamate is not a first-line antiepileptic
 lamotrigine (Lamictal #)                                                          agent and is recommended only in patients
                                                                                   who have shown an inadequate response to
 lamotrigine (Lamictal Starter Kit)                  PA
                                                                                   alternative treatments and whose epilepsy
 lamotrigine, extended-release (Lamictal XR,         PA
                                                                                   is so severe that the benefits outweigh the
     Lamictal XR Start Kit)
                                                                                   potential risks of aplastic anemia or liver
 lamotrigine, orally disintegrating tablet           PA
                                                                                   failure.
     (Lamictal ODT, Lamictal ODT Start Kit)
                                                                                • Lamotrigine has been associated with
 levetiracetam (Keppra #)
                                                                                   serious rashes, which required
 levetiracetam extended-                             PA                            hospitalization and/or discontinuation of
     release (Keppra XR)                                                           treatment. Most cases of life-threatening
 lorazepam                                                                         rashes occurred within the first two to eight
 lorazepam powder                                    PA                            weeks of treatment.
 methsuximide (Celontin)                                                        • Phenytoin may cause gingival hyperplasia;
 oxcarbazepine (Trileptal #)                                                       the incidence may be reduced by good oral
 phenobarbital (generics)                                                          hygiene, including frequent brushing and
 phenytoin (Dilantin Infatab)                                                      flossing.
 phenytoin (Phenytek #)                                                         • Valproic acid and its derivatives have been
 phenytoin 100 mg/4 ml unit dose suspension          PA                            associated with hepatic failure resulting in
 phenytoin capsule, suspension 125 mg/5ml                                          fatalities. Liver function tests should be
     (Dilantin #)                                                                  performed prior to initiating therapy and
 pregabalin (Lyrica)                                 PA                            subsequently at frequent intervals,
 primidone (Mysoline #)                                                            especially during the first six months of
 rufinamide (Banzel)                                 PA                            therapy.
 tiagabine (Gabitril)                                PA > 18 years
 topiramate (Topamax #)                              PA > 18 years
 valproate (Depacon, Depakene #)
 valproic acid (Depakene #)
 valproic acid (Stavzor)                             PA
 vigabatrin (Sabril)                                 PA
 zonisamide (Zonegran #)
# This is 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.


May 3, 2010                                                          86
Therapeutic Class and Clinical Criteria Tables

Table 20. Anticonvulsants (cont.)
II. Therapeutic Uses
    FDA-Approved, for example:
    • seizure disorder
    • migraine prophylaxis (Stavzor, Topamax)
    • postherpetic neuralgia (pregabalin)
    • diabetic peripheral neuropathy (pregabalin)
    • adjunctive treatment for partial seizures
    • fibromyalgia (pregabalin)
    • bipolar disorder (Stavzor)

    Non FDA-Approved, for example:
    • anxiety/panic disorder
    • bipolar disorder
    • essential tremor
    • hot flashes
    • neuropathic pain
    • peripheral neuropathy
    • restless leg syndrome
    • trigeminal neuralgia

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose and frequency.
     • Additional criteria may apply, depending upon diagnosis and/or requested medication (see below).

      SmartPA: Claims for tiagabine, and topiramate in members > 18 years, will usually process at the pharmacy without a
      prior authorization request if, over the last 120 days, the member has MassHealth pharmacy claims for a cumulative
      supply of at least 90 days of the anticonvulsant.†

      SmartPA: Claims for pregabalin will usually process at the pharmacy without a prior authorization if the member has
      MassHealth pharmacy claims for any of the following drugs within the part 13 months: ethosuximide (Zarontin),
      felbamate (Felbatol), phenytoin (Dilantin), primidone (Mysoline).†

      SmartPA: Claims for pregabalin will usually process at the pharmacy without a prior authorization request if the
      member has a history of MassHealth medical claims for epilepsy and if, over the last 120 days, the member has
      MassHealth pharmacy claims for a cumulative supply of at least 90 days of the anticonvulsant.†

    Seizure Disorder
    Pregabalin, tiagabine, and topiramate
    • Documentation of the following is required:
      o seizure diagnosis; and
      o occurrence of seizures despite standard anticonvulsant monotherapy (pregabalin only).

      SmartPA: Claims for tiagabine and topiramate in members > 18 years, and claims for pregablin will usually process at
      the pharmacy without a prior authorization request if the member has a history of MassHealth medical claims for
      epilepsy, or if the member has MassHealth pharmacy claims for any of the following drugs within the past 13 months:
      ethosuximide (Zarontin), felbamate (Felbatol), phenytoin (Dilantin), primidone (Mysoline). †

    Seizure Disorder
    Lamotrigine extended-release, levetiracetam extended-release
    • Documentation of the following is required:
      o seizure diagnosis; and
      o medical necessity for the extended-release formulation over the immediate release formulation.




May 3, 2010                                                 87
Therapeutic Class and Clinical Criteria Tables

Table 20. Anticonvulsants (cont.)
    Seizure Disorder
    Lacosamide tablet
    • Documentation of the following is required:
      o partial-onset seizures;
      o member is > 17 years of age;
      o currently on treatment regimen for seizure control;
      o inadequate response to at least two of the following: carbamazepine, gabapentin, lamotrigine, topiramate,
        valproic acid, divalproex; and
      o a daily dose of not more than 400 mg/day.

    Seizure Disorder
    phenytoin 100 mg/4 ml suspension
    • Documentation of the following is required:
      o rationale for use of unit dose product.

    Seizure Disorder
    Rufinamide
    • Documentation of the following is required:
      o Lennox-Gastaut Syndrome;
      o member is > 4 years of age;
      o currently on a treatment regimen for seizure control;
      o inadequate response to at least one of the following: topiramate, lamotrigine, valproic acid or felbamate; and
      o a daily dose of not more than 3,200 mg/day.

    Seizure Disorder
    Stavzor (valproic acid)
    • Documentation of the following is required:
      o seizure diagnosis; and
      o documentation of an inadequate response to generic valproic acid.

    Infantile Spasms
    vigabatrin
    • Documentation of the following is required:
      o appropriate diagnosis; and
      o daily dose is for < 150 mg/kg/day.

    Diazepam rectal gel: quantities > 5 kits (10 syringes/month)
    • Documentation of the following is required:
      o medical necessity for greater than five kits (10 syringes/month); and
      o the provider is a neurologist or a consult has been provided from a neurologist.

    Powders (diazepam, lorazepam, and gabapentin)
    • Documentation of compelling rationale why commercially available alternatives (oral solution, tablets, capsules)
      cannot be used is required.

IV. Evaluation Criteria for Non seizure Diagnoses
    • Documentation of the following is required:
      o medical necessity for requested medication; and
      o details about trials of less costly alternatives for a particular indication (see below).

    Anxiety/Panic Disorder
    Tiagabine and topiramate
    • Documentation of an inadequate response, adverse reaction, or contraindication to two or more of the following
      classes is required:
      o benzodiazepines
      o SSRIs; and
      o tricyclic antidepressants or buspirone.


May 3, 2010                                                      88
Therapeutic Class and Clinical Criteria Tables

Table 20. Anticonvulsants (cont.)
    Bipolar Disorder
    Tiagabine and topiramate
    • Documentation of an inadequate response, adverse reaction, or contraindication to at least one agent from each
      of the following categories is required:
      o atypical antipsychotics
      o conventional anticonvulsants (see list in Section V. Appendix); or
      o lithium.

    Bipolar Disorder
    Stavzor (valproic acid)
    • Documentation of an inadequate response, adverse reaction, or contraindication to the following is required:
      o at least one atypical antipsychotic
      o lithium; and
      o documentation of an inadequate response to generic valproic acid.

    Essential Tremor
    Tiagabine and topiramate
    • Documentation is required for an inadequate response, adverse reaction, or contraindication to less costly alternatives
      such as:
      o benzodiazepines;
      o beta-blockers; and
      o conventional anticonvulsants (see list in Section V. Appendix).

    Hot Flashes
    Tiagabine and topiramate
    • Documentation of an inadequate response, adverse reaction, or contraindication to less costly alternatives, is
      required, for example:
      o clonidine;
      o hormone therapy; and
      o SSRIs.

    Fibromyalgia
    Pregabalin
    • Documentation of the following is required:
      o inadequate clinical response, adverse reaction, or contraindication to gabapentin;
      o inadequate clinical response, adverse reaction, or contraindication to gabapentin; and
      o inadequate clinical response, adverse reaction, or contraindication to one of the following: a
        tricyclic antidepressant, cyclobenzaprine, or an SSRI.

    Migraine
    Tiagabine and topiramate
    • Documentation of an inadequate response, adverse reaction, or contraindication to two or more of the following
      prophylactic medication classes is required:
      o beta-blockers
      o calcium channel blockers
      o conventional anticonvulsants (see list in Section V, Appendix)
      o tricyclic antidepressants

    Migraine
    Stavzor (valproic acid)
    • Documentation of an inadequate response, adverse reaction, or contraindication to two or more of the following
      prophylactic medication classes is required:
      o beta-blockers;
      o calcium channel blockers;
      o tricyclic antidepressants; and
      o documentation of an inadequate response to generic valproic acid.



May 3, 2010                                                   89
 Therapeutic Class and Clinical Criteria Tables

Table 20. Anticonvulsants (cont.)
     Postherpetic Neuralgia, Peripheral Neuropathy, Diabetic Neuropathy, and Neuropathic Pain
     Tiagabine and topiramate
     • Documentation of an inadequate response, adverse reaction, or contraindication to at least one tricyclic
       antidepressant is required.

     Postherpetic Neuralgia and Diabetic Neuropathy
     Pregabalin
     • Documentation of the following is required:
       o inadequate clinical response, adverse reaction, or contraindication to at least one tricyclic
         antidepressant and gabapentin.

     Restless Leg Syndrome
     Tiagabine and topiramate
     • Documentation is required of an inadequate response, adverse reaction, or contraindication to less costly
       alternatives such as the following:
       o benzodiazepines;
       o clonidine; and
       o dopamine agonists, for example, ropinirole, or levodopa.

 V. Appendix
    Examples of Conventional Anticonvulsants:
    • carbamazepine
    • divalproex sodium
    • lamotrigine
    • phenytoin
    • primidone
    • valproic acid
 †
 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: 6/2003                                                     Last Revised Date: 2/2010




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Therapeutic Class and Clinical Criteria Tables

                                           MassHealth Evaluation Criteria
                                      Table 21. Beta-Adrenergic Blocking Agents
Drug Category: Cardiovascular
Medication Class/Individual Agent: Beta-Adrenergic Blocking Agents (Beta-Blockers)

I. Prior-Authorization Requirements
  Drug                              PA             Adrenergic            Clinical
  Name                              Status         Receptor              Notes
                                                   Blocking
                                                   Activity
 acebutolol (Sectral #)                            β1                    Receptor blocking selectivity:
 atenolol (Tenormin #)                             β1                    • β1 receptors are predominant in the heart and
 atenolol/chlorthalidone                                                    kidney; β2 receptors are predominant in the
    (Tenoretic #)                                                           arteriolar smooth muscle, liver, lungs, and
 betaxolol (Kerlone #)                             β1                       pancreas.
 bisoprolol (Zebeta #)                             β1                    • Cardioselective beta-blockers possess greater
 bisoprolol/hydrochlorothiazide                                             affinity for β1 receptors than β2 receptors.
    (Ziac #)                                                             • At low doses, cardioselective beta-blockers
 carvedilol (Coreg #)                              β1 β2 α1                 may be safer than nonselective agents in
 carvedilol extended-release            PA         β1 β2 α1                 patients with asthma, diabetes, COPD, and
    (Coreg CR)                                                              peripheral vascular disease.
 esmolol # (Brevibloc)                             β1                    • Cardioselective agents may also inhibit β2
 labetalol (Trandate #,                            β1 β2 α1                 receptors at higher doses.
    Normodyne #)                                                         • Alpha-blockade has the potential to produce
 metoprolol (Lopressor #,                          β1                       more orthostatic hypotension.
    Toprol XL #)
 metoprolol/                                                             Intrinsic sympathomimetic activity (ISA):
    hydrochlorothiazide                                                  • Acebutolol, carteolol, penbutolol, and pindolol
    (Lopressor HCT #)                                                        possess ISA.
 nadolol (Corgard #)                               β1 β2                 • Agents with ISA may not be as
 nadolol/bendroflumethiazide                                                 cardioprotective as other beta-blockers and
    (Corzide #)                                                              should not be used for myocardial infarction
 nebivolol (Bystolic)                   PA         β1                        (MI) prophylaxis.
 penbutolol (Levatol)                   PA         β1 β2
 pindolol (Visken #)                               β1 β2                 Use in heart failure:
 propranolol (Inderal #)                           β1 β2                 • Metoprolol extended-release and carvedilol
 propranolol extended-release           PA                                  are approved for heart failure.
    (InnoPran XL)
 propranolol/                                                            Use in diabetes:
     hydrochlorothiazide                                                 • Beta-blockers may mask some symptoms
    (Inderide #)                                                           of hypoglycemia.
 sotalol (Betapace #)                              β1 β2                 • Nonselective beta-blockers may potentiate
 timolol (Blocadren #)                             β1 β2                    insulin-induced hypoglycemia and delay
 timolol/ hydrochlorothiazide                                               recovery of serum glucose levels.

                                                                         Other concomitant disorders:
                                                                         • Beta-blockers may offer advantages for
                                                                            hypertensive patients with the following
                                                                            conditions: angina, migraines, selected
                                                                            ventricular and supraventricular arrhythmias.
                                                                         • Nonselective All patients should receive a
                                                                            beta-blocker post MI, unless they have an
                                                                            absolute contraindication or have shown
                                                                            intolerance.
# This is 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.




May 3, 2010                                                         91
Therapeutic Class and Clinical Criteria Tables

Table 21. Beta-Adrenergic Blocking Agents (cont.)

II. Therapeutic Uses
    FDA-approved, for example:
    • angina pectoris
    • cardiac arrhythmias
    • heart failure
    • hypertension
    • hypertrophic subaortic stenosis
    • left ventricular dysfunction following MI
    • migraine prophylaxis
    • myocardial infarction
    • pheochromocytoma
    • post-myocardial infarction

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose and frequency.
     • Additional criteria may apply depending upon requested medication (see below).

    Levatol, Bystolic:
    • Documentation of all of the following is required:
      o an adverse reaction or an inadequate response to at least two different generic beta-blockers;
      o documentation that the member is currently on diuretic therapy or documentation of failed trial, adverse
        reaction, or contraindication to a diuretic; and
      o documentation that the member is not a candidate for, or failed other classes of medication including ACEI,
        ARBs, and CCBs.

    InnoPran XL
    • Documentation of an adverse reaction (not class specific) or inadequate response to a long-acting propranolol
      formulation that does not require prior authorization is required.

      SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has a
      history of MassHealth medical claims for hypertension, post-MI, or migraine, and MassHealth pharmacy claims
      for a formulation of propranolol that does not require prior authorization.†

    Coreg CR
    • Documentation of the medical necessity for Coreg CR over immediate-release carvedilol
†
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: 4/2003                                                               Last Revised Date: 2/2010




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Therapeutic Class and Clinical Criteria Tables

                                            MassHealth Evaluation Criteria
                                      Table 22. Calcium Channel Blocking Agents

Drug Category: Cardiovascular
Medication Class/Individual Agent: Calcium Channel Blocking Agents (CCB)

I. Prior-Authorization Requirements
  Drug Name                        PA Status                 Clinical Notes
  Benzothiazepines                                           Indications:
  diltiazem (Cardiazem #, Cartia,                            • Nimodipine is FDA approved only for
    Dilacor #, Tiazac #)                                        subarachnoid hemorrhage.
  Dihydropyridines                                           • Bepridil, diltiazem (short acting), nifedipine
  amlodipine (Norvasc #)                                        (immediate release), and nimodipine are not FDA
  amlodipine/atorvastatin (Caduet)     PA                       approved for the treatment of essential
  amlodipine/benazepril (Lotrel)       PA                       hypertension.
  amlodipine/olmesartan (Azor)         PA                    • Sustained-release nifedipine and amlodipine have
  amlodipine/telmisartan               PA                       been shown to have comparable efficacy in
  amlodipine/valsartan (Exforge)       PA                       African-Americans with hypertension.
  felodipine (Plendil #)
  isradipine (Dynacirc #)                                    Precautions/warnings:
  isradipine extended-release          PA                    • Formulations of calcium channel blockers that
    (Dynacirc CR)                                               contain the same active ingredient may not be “A”
  nicardipine (Cardene #)                                       rated to each other and, therefore, should not be
  nifedipine (Adalat #, Nifedical,                              interchanged.
    Procardia #)                                             • Two sustained-release verapamil products
  nimodipine                                                    (Covera-HS and Verelan PM – not
  nisoldipine (Sular #)                PA                       interchangeable) were designed to be given at
  Diphenylalkylamines                                           bedtime. With a 4-5 hour delay in release, it is
  trandolapril/verapamil (Tarka)       PA                       intended to prevent the early morning surge in
                                                                blood pressure.
  verapamil (Calan #, Covera-HS,
    Verelan #, Isoptin #)
                                                             Adverse events:
                                                             • Side effects caused by vasodilation such as
                                                               dizziness, flushing, headache, and peripheral
                                                               edema, occur more frequently with
                                                               dihydropyridines.
# This is 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.

II. Therapeutic Uses
    FDA-Approved, for example:
    • hypertension
    • coronary artery disease (stable or variant angina)
    • arrhythmias, paroxysmal supraventricular tachycardia
    • subarachnoid hemorrhage (nimodipine)

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon requested medication (see below).




May 3, 2010                                                         93
Therapeutic Class and Clinical Criteria Tables

Table 22. Calcium Channel Blocking Agents (cont.)

    Dynacirc CR and nisoldipine
    • Documentation of one of the following is required:
      o an adverse reaction (not class specific) or inadequate response to at least one reference CCB
        when prescribed at therapeutic doses for an appropriate period of time; or
      o rationale why a CCB that does not require prior authorization has not been tried.

      SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has
      MassHealth medical claims for an appropriate clinical indication, for example: hypertension, migraine, pulmonary
      hypertension, or Reynaud’s syndrome, and MassHealth pharmacy claims for at least one generic non-prior-
      authorization CCB.†

    Combination Products (Azor, Caduet, Exforge, Lotrel, Tarka, Twynsta):
    • Documentation of one of the following is required:
      o treatment with stable doses of the separate agents for a minimum of three months; or
      o stabilized for at least three months on the combination product; or
      o medical necessity for one agent in patients with complex, multiple, comorbid conditions.
†
 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: 4/2003                                                             Last Revised Date: 2/2010




May 3, 2010                                                  94
Therapeutic Class and Clinical Criteria Tables

                                                 MassHealth Evaluation Criteria
                                              Table 23. Respiratory Inhalant Products

Drug Category: Respiratory Tract Agents
Medication Class/Individual Agents: Respiratory Inhalants
I. Prior-Authorization Requirements
  Drug Name                       PA Status                         Clinical Notes
  Anticholinergics                                                  Quick-relief medications:
  ipratropium (Atrovent #,                                          • Inhaled short-acting selective beta2-agonists are therapy of choice for relief
      Atrovent HFA)                                                   of acute symptoms.
  tiotropium (Spiriva)                                              • Increasing use of short-acting beta2- agonists or use of
  Combination Products                                                more than one canister/month may indicate over
  albuterol/ipratropium                                               reliance on this drug and inadequate asthma control.
      (DuoNeb #, Combivent)                                         • Daily scheduled use of short-acting beta2-
  budesonide/formoterol           PA                                  increasing agonists is generally not recommended.
      (Symbicort)                                                   • Long acting beta2-agonists, such as formoterol and salmeterol, are not
  fluticasone/salmeterol          PA                                  recommended for treatment of acute symptoms or exacerbations.
      (Advair HFA) 1
  fluticasone/salmeterol          PA                                Maintenance medications:
      (Advair diskus) 1                                             Inhaled corticosteroids are considered the most effective treatment for the
  Corticosteroids                                                   symptoms of persistent asthma. The National Heart, Lung, and Blood
  beclomethasone (Qvar)                                             Institute (NHLBI) and World Health Organization (WHO) guidelines
  budesonide (Pulmicort)                                            recommend inhaled corticosteroids to be first-line asthma-controller
  ciclesonide (Alvesco)                                             medications.
  flunisolide (Aerobid,
      Aerobid-M)
                                                                    For treatment of asthma, inhaled long-acting beta2-agonists
  fluticasone (Flovent, Flovent
                                                                    • should not be the first medicine used;
      HFA)
                                                                    • should be added only if other medications, including the use of low-or-
  mometasone (Asmanex)
                                                                      medium-dose corticosteroids, do not adequately control symptoms;
  triamcinolone (Azmacort)
                                                                    • should be used concurrently with anti-inflammatory medications; and
  Mast Cell Stabilizers
                                                                    • may increase the severity of asthma exacerbations and may increase the
  nedocromil (Tilade)
                                                                      risk of asthma-related deaths.
  Sympathomimetics
  arformoterol (Brovana)          PA                                The incidence of oral candidiasis with inhaled corticosteroids may be
  albuterol (AccuNeb #, ProAir                                      reduced by using a spacer/holding chamber and rinsing the mouth with water
      HFA, Proventil #)                                             after inhalation.
  albuterol, inhaler (Proventil,  PA
     Proventil HFA, Ventolin,                                       Exersise-induced bronchospasm:
     Ventolin HFA)                                                  • Inhaled selective beta2-agonists are the treatment of choice.
  formoterol (Foradil,            PA
     Performonist) 1                                                The FDA-issued public health advisory about the use of inhaled long-
  levalbuterol (Xopenex,          PA                                acting beta2-agonists is available at
     Xopenex HFA)                                                   www.fda.gov/Drugs/DrugSafety/PublicHealthAdvisories/ucm162678.htm
  metaproterenol, inhalation
     solution (Alupent #)
  metaproterenol, inhaler         PA
     (Alupent)
  pirbuterol (Maxair)             PA

    salmeterol (Serevent) 1                PA
1
  PA also required for quantity greater than one inhaler per month.
# This is 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.




May 3, 2010                                                                  95
Therapeutic Class and Clinical Criteria Tables

Table 23. Respiratory Inhalant Products (cont.)
II. Therapeutic Uses
    FDA-approved, for example:
    • asthma
    • chronic obstructive pulmonary disease (COPD)
    • exercise-induced bronchospasm (EIB)

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon diagnosis and/or requested medication (see below).

    Budesonide/formoterol and fluticasone/salmeterol and
    • Documentation of one of the following is required.
      o COPD; or
      o Documentation of asthma and one of the following:
         inadequate response, adverse reaction, or contraindication to inhaled or oral corticosteroids;
         stable therapy; or
         moderate-to-severe persistent asthma.

      SmartPA: Claims will usually process at the pharmacy when less than or equal to one inhaler/month without a prior
      authorization request if the member has a history of MassHealth medical claims for COPD, or, if the member has a history
      of MassHealth pharmacy claims for inhaled or oral corticosteroids, fluticasone/salmeterol, or budesonide/formoterol
      within the past 120 days.†

    Formoterol or salmeterol
    • Documentation of one of the following is required:
      o documentation of COPD or EIB; or
      o documentation of asthma and concurrent therapy with an inhaled corticosteroid.

      SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has a history of
      MassHealth medical claims for COPD or EIB, or if the member has a history of MassHealth pharmacy claims for inhaled
      corticosteroids within the past 60 days.†

    Arformoterol and formoterol nebulizers
    • Documentation of all of the following is required:
      o COPD;
      o rationale for nebulized formulation;
      o quantity limit of 120 mL/month; and
      o member > 18 years of age.

    Short-acting Beta2- agonists: Alupent, Maxair, Proventil, Ventolin, Xopenex
    • Documentation of an inadequate response, adverse reaction, or contraindication to generic albuterol inhalers or
      nebulizer solution is required.
†
 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: 12/2006                                                                 Last Revised Date: 11/2009




May 3, 2010                                                  96
Therapeutic Class and Clinical Criteria Tables


                                                    MassHealth Evaluation Criteria
                                                    Table 24. Atypical Antipsychotics
 Drug Category: Central Nervous System (CNS)
 Medication Class/Individual Agents: Atypical Antipsychotics

 I. Prior-Authorization Requirements
  Drug Name                          PA Status                           Clinical Notes
  aripiprazole tablet (Abilify)      PA > 30 units/month                 • Limited scientific data supports the concomitant use of atypical
  aripiprazole injection (Abilify                                          antipsychotics. It is recommended that monotherapy trials be attempted
      IM)                                                                  before polypharmacy is used.
  aripiprazole, orally               PA                                  • Dissolvable tablets do not have a faster onset of action compared to
     disintegrating tablet (Abilify                                        their conventional oral dosage forms. They possess the same side
     Discmelt)                                                             effects and have similar pharmacokinetic profiles as the oral tablet.
  aripiprazole solution (Abilify)    PA > 750 ml/month                     Since dissolvable tablets offer no therapeutic advantage, and they are
  asenapine (Saphris)                PA                                    more costly than other oral formulations, all dissolvable tablets will
  clozapine (Clozaril #)                                                   require prior authorization. Asenapine has minimal to no absorption if
  clozapine, orally disintegrating   PA                                    swallowed and must be dissolved in the mouth to be absorbed via
     tablet (Fazaclo)                                                      buccal/sublingual sites.
  fluoxetine/olanzapine              PA                                  • Expert consensus has stated that all antipsychotics are to be considered
     (Symbyax)                                                             equally efficacious.
  iloperidone (Fanapt)               PA                                  • All antipsychotics have a black box warning for increased mortality in
  olanzapine injection (Zyprexa                                            elderly patients with dementia related psychosis.
     IM)                                                                 • Atypical antipsychotics have been associated with substantial weight
  olanzapine, orally disintegrating PA                                     gain. This risk is statistically greater with some products compared to
     tablet (Zyprexa Zydis)                                                others.
  olanzapine, pamoate injection      PA > 2                              • In November 2003, the FDA mandated that the following information
     210 mg, 300 mg                  injections/month                      be added to the WARNINGS section of all atypical antipsychotic drug
  olanzapine, pamoate injection      PA > 1 injection/month                labeling. Hyperglycemia in extreme progressing to ketoacidosis,
     405 mg                                                                hyperosmolar coma and/or death has been reported for this class of
  olanzapine tablet (Zyprexa)        PA > 30 units/month                   drugs. Fasting glucose should be obtained at the beginning of treatment
  paliperidone injection (Invega     PA > 2 units/month                    and periodically. Patients with established diagnosis of diabetes
     Sustenna)                       within the first 30 days              mellitus should be monitored for worsening of glycemic control. (For
                                     of therapy; PA > 1                    complete details see package insert.)
                                     unit/month after 30                 • A consensus statement issued by the APA, ADA and others suggested
                                     days of therapy                       a scheduled monitoring of the following patients on these drugs:
  paliperidone tablet (Invega)       PA for new starts only.               weight/BMI, waist circumference, blood pressure, fasting glucose, and
                                     See criteria below.                   fasting lipid profile.1
  quetiapine (Seroquel)              PA > 90 units/month                 • Antipsychotic induced metabolic complications such as weight
  quetiapine extended-release        PA > 30 units/month                   increases, glucose increases and triglyceride increases are more
     (Seroquel XR) 150 mg                                                  pronounced in the child and adolescent population compared to the
     and 200 mg                                                            adult population.
  quetiapine extended-release        PA > 60 units/month                 1
     (Seroquel XR) 50 mg, 300 mg                                             American Diabetes Association; American Psychiatric Association;
     and 400 mg                                                              American Association of Clinical Endocrinologists; North American
  risperidone tablet (Risperdal #)   PA > 60 units/month                     Association for the Study of Obesity. Consensus development
                                                                             conference on antipsychotic drugs and obesity and diabetes. J Clin
  risperidone injection (Risperdal   PA > 2 units (2
                                                                             Psych 2004;65(2):267-272.
     Consta)                         syringes) /month
  risperidone, orally disintegrating PA
     tablet (Risperdal M #)
  risperidone solution (Risperdal    PA > 480 ml/month
     #)
  ziprasidone injection (Geodon)
  ziprasidone (Geodon)               PA > 60 units/month
  # This is 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.




May 3, 2010                                                                  97
Therapeutic Class and Clinical Criteria Tables

    Table 24. Atypicial Antipsychotics (cont.)
    II. Therapeutic Uses
        FDA-approved, for example:
        • bipolar disorder
        • irritability in autism
        • schizophrenia

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply depending upon diagnosis and/or requested medication (see below).

      Monotherapy
       Fanapt, Invega tablet and Saphris
      • Documentation of the following is required:
        o member is new to MassHealth and previously stabilized on medications (please note: this does not include the use of
          samples); or
        o a trial with a generic atypical antipsychotic; and
        o trials with two other antipsychotics.

      SmartPA: Claims for Invega will usually process at the pharmacy without a prior authorization request if the member has
      a MassHealth history of pharmacy claims of Invega for 90 days in the past 120 days. †

      Rapidly dissolving
      Abilify Discmelt, Fazaclo, risperidone orally dissolving tablet, Zyprexa Zydis
      • Documentation of the following is required:
        o member needs 30 day stabilization period and is only on liquids and injectables at this time. They will be switched
          to tablet/capsule preparations after this period; or
        o medical necessity for the use of an orally disintegrating formulation for other than the above reason.

      Duplicate therapy for ≥60 days of at least 2 of the following:
      Abilify, Fanapt, Geodon, Invega, risperidone, Saphris, Seroquel, Seroquel XR, Zyprexa
      • Documentation of the following is required:
        o an inadequate response or contraindication to monotherapy with each requested atypical antipsychotic. Please
          choose the best reason on the PA form or explain the medical necessity for duplicate therapy.

      Exceeding Quantity limits Oral preparations
      Abilify solution (>750 ml/month), Abilify tablet (>30 units/month), Geodon (>60 units/month), risperidone
      solution (>480 ml/month), risperidone tablet (>60 units/month), Seroquel (>90 units/month), Seroquel XR 150 mg
      and 200mg (> 30 units/month), Seroquel XR 50mg, 300mg and 400mg (>60 units/month), Zyprexa tablet (>30
      units/month)
      • Documentation of the following is required:
        o rationale why dose cannot be consolidated; or
        o rationale why member requires dosing exceeding FDA-approved intervals.

      Exceeding Quantity limits Injectable preparations:
      Invega Sustenna >2 units (2 syringes)/month within the first 30 days, >1 unit (1 syringe)/month after 30 days,
      Risperdal Consta >2 units (2 syringes)/30 days, Zyprexa Relprevv 210 mg, 300 mg > 2 units (2 syringes)/month
      and Zyprexa Relprevv 405 mg > 1 unit (1 syringe)/month
      • Documentation of the following is required:
        o medical necessity for exceeding the FDA-approved quantity limits.
†
 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: 3/2010                                                         Last Revised Date: 3/2010
May 3, 2010                                                    98
  Therapeutic Class and Clinical Criteria Tables

                                           MassHealth Evaluation Criteria
                                         Table 25. Intranasal Corticosteroids

Drug Category: Cough, Cold and Allergy
Medication Class/Individual Agent: Intranasal Steroids

I. Prior-Authorization Requirements
 Drug Name                              PA Status     Average        Clinical Notes
                                                      Monthly
                                                      Cost $
 beclomethasone nasal spray             PA            $130.15        • Intranasal corticosteroids are effective in managing
    (Beconase AQ)                                                      symptoms of itching, nasal congestion, rhinorrhea, and
 budesonide nasal spray (Rhinocort      PA            $92.84           sneezing associated with perennial and seasonal rhinitis.
    Aqua)                                                            • Symptoms may begin to improve in 2-3 days but full
 ciclesonide nasal spray (Omnaris       PA            $88.01           benefit may not be achieved for 2-3 weeks.
    AQ)                                                              • Dosage may be reduced after a response has been
 flunisolide nasal spray (generics,     PA > 1        $32.65 (#)       achieved.
    Nasarel #)                          inhaler/                     • At the recommended doses, side effects are usually
                                        month                          minimal and include stinging, sneezing, headache and
 fluticasone furoate nasal spray        PA            $91.94           epistaxis.
    (Veramyst)
 fluticasone propionate nasal spray        PA > 1        $26.80 (#)     FDA-approved ages:
    (Flonase #)                            inhaler/                     • > 6 years of age: Beconase AQ, Rhinocort Aqua,
                                           month                            Omnaris, flunisolide 0.025%, flunisolide 29 mcg
  mometasone nasal spray (Nasonex)         PA > 4        $90.48         • > 4 years of age: fluticasone propionate
                                           years and                    • > 2 years of age: Nasacort AQ, Nasonex, Veramyst
                                           >1
                                           inhaler/
                                           month
  triamcinolone nasal spray (Nasacort PA > 4             $88.77
     AQ)                                   years and
                                           PA > 1
                                           inhaler/
                                           month
# This is 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.
$
    This value represents the average monthly cost of the most commonly prescribed quantities as of 7/2009. Where applicable,
   cost represents that of an “A”- rated generic equivalent (#).

II. Therapeutic Uses
    FDA-approved, for example:
    • rhinitis

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon diagnosis and requested medication (see below).

    Beconase AQ (1 inhaler/month), Nasacort AQ (1 inhaler/month), Nasonex (1 inhaler/month), Omnaris (1
    inhaler/month), Rhinocort Aqua (1 inhaler/2 months) and Veramyst (1 inhaler/month) for members 6 years of age
    and older
    • Documentation of all of the following is required:
      o failure of an adequate trial of both flunisolide (0.025% spray or 29 mcg spray) and fluticasone propionate spray; or
      o an adverse reaction or contraindication to both flunisolide (0.025% spray or 29 mcg spray) and fluticasone
        propionate spray.
    • For requests for Veramyst, in addition to the above criteria, documentation of the following is required:
      o compelling rationale (medical necessity) why brand name Veramyst would offer a therapeutic advantage over the
        generic therapeutically equivalent fluticasone propionate product.
  May 3, 2010                                                   99
Therapeutic Class and Clinical Criteria Tables

Table 25. Intranasal Corticosteroids (cont.)

  Beconase AQ (1 inhaler/month), Nasacort AQ (1 inhaler/month), Nasonex (1 inhaler/month), Omnaris (1
  inhaler/month), Rhinocort Aqua (1 inhaler/2 months) and Veramyst (1 inhaler/month) for members 4 and 5 years
  of age
  • Documentation of all of the following is required:
    o failure of an adequate trial of fluticasone propionate spray; or
    o an adverse reaction or contraindication to fluticasone propionate spray.
  • For requests for Veramyst, in addition to the above criteria, documentation of the following is required:
    o compelling rationale (medical necessity) why brand name Veramyst would offer a therapeutic advantage over the
      generic therapeutically equivalent fluticasone propionate product.

  Beconase AQ (1 inhaler/month), Omnaris (1 inhaler/month), Rhinocort Aqua (1 inhaler/2 months) and Veramyst (1
  inhaler/month) for members less than 4 years of age
  • Documentation of all of the following is required:
    o failure of an adequate trial of Nasonex or Nasacort AQ; or
    o an adverse reaction or contraindication to Nasonex or Nasacort AQ .
  • For requests for Veramyst, in addition to the above criteria, documentation of the following is required:
    o failure of an adequate trial of a therapeutically equivalent formulation; and
    o compelling rationale (medical necessity) why brand name Veramyst would offer a therapeutic advantage over the
      generic therapeutically equivalent fluticasone propionate product.

  Flunisolide 0.025% (> 1 inhaler/month), flunisolide 29 mcg (> 1 inhaler/month), fluticasone propionate (> 1
  inhaler/month)
  • Documentation of all of the following is required:
    o failure of an adequate trial of the manufacturer’s recommended doses; and
    o failure of an adequate trial with less costly alternatives (e.g. loratadine).

  Beconase AQ (>1 inhaler/month), Nasacort AQ (> 1 inhaler/month), Nasonex (> 1 inhaler/month), Omnaris (>1
  inhaler/month), Rhinocort Aqua (>1 inhaler/2 months) and Veramyst (>1 inhaler/month)
  • Documentation of all of the following is required:
    o member must meet age-specific criteria for individual agent requested (see approval criteria for individual agent
      above);
    o an inadequate response to the manufacturer’s recommended does; and
    o an inadequate response to less costly alternatives (e.g. loratadine)

Original Effective Date: 2/2009                                                           Last Revised Date: 11/2009




May 3, 2010                                                 100
Therapeutic Class and Clinical Criteria Tables

                                               MassHealth Evaluation Criteria
                                              Table 26. Oral Antidiabetic Agents
Drug Category: Endocrine/Metabolic
Medication Class/Individual Agent: Oral Antidiabetic Agents
I. Prior-Authorization Requirements
  Drug Name                                   PA           Average              Clinical Notes
                                              Status       Monthly Cost $
  Alpha-Glucosidase Inhibitors                                                  Alpha-glucosidase inhibitors:
  acarbose (Precose #)                        PA           $69.99               • If hypoglycemia occurs, treat with glucose
  miglitol (Glyset)                                        $26.52- $178.30         rather than sucrose.
  Biguanides                                                                    • Not recommended for patients with
  metformin (Glucophage #)                    PA           $5.51-$9.74             significant renal dysfunction (serum
  metformin extended-release                               $86.57-$273.91          creatinine > 2 mg/dl).
      (Fortamet, Glumetza)                                                      • Contraindications include inflammatory
  metformin extended-release                               $7.76-$19.51            bowel disease, colonic ulceration, and
     (Glucophage XR #)                                                             intestinal obstruction.
  metformin solution (Riomet)                              $105.54
  Dipeptidyl peptidase-4 Inhibitors                                             Biguanides:
  saxagliptin (Onglyza)                       PA            $171.60             • Hold metformin therapy for 48 hours after
                                                                                   receiving iodinated contrast.
  sitagliptin (Januvia)                       PA            $171.60
                                                                                • May cause lactic acidosis; contraindicated in
  Meglitinides
                                                                                   patients predisposed to acidosis (e.g., major
  nateglinide (Starlix)                       PA           $145.08
                                                                                   surgery, congestive heart failure, hepatic
  repaglinide (Prandin)                       PA           $168.02                 failure).
  Sulfonylureas - First Generation                                              • Contraindicated in females and males with
  chlorpropamide (Diabenese #)                             $5.10-$10.80            renal disease or dysfunction (e.g., serum
  tolazamide (Tolinase #)                                  $27.23                  creatinine greater than or equal to 1.4 mg/dl
  tolbutamide                                              $5.68                   and 1.5 mg/dl, respectively).
                                                                                • In small studies, some obese women with
  Sulfonylureas - Second Generation
                                                                                   polycystic ovary syndrome experienced a
  glimepiride (Amaryl #)                       PA          $6.05                   return of normal menses and ovulation when
  glipizide (Glucotrol #)                                  $6.68                   treated with metformin.
  glipizide extended-release                               $11.14-$38.07
     (Glucotrol XL #)                                                           Meglitinides:
  glyburide (Diabeta)                                      $8.82-$31.82         • Take before meals; hold dose if meal is
  glyburide (Micronase #)                                  $8.36-$14.73           missed.
  glyburide, micronized (Glynase #)                        $7.46                • Use with caution in patients with hepatic
                                                                                  impairment.
  Thiazolidinediones
  pioglitazone (Actos)                                     $202.49              Sulfonylureas:
  rosiglitazone (Avandia)                                  $95.53-$173.55       • Use with caution in elderly patients and
  Combination Products                                                              patients with renal or hepatic impairment.
  glimepiride/pioglitazone (Duetact)          PA           $212.31
                                                                                Thiazolindinediones:
  glimepiride/rosiglitazone                   PA           $123.17-$211.68      • Use with caution in patients with edema.
     (Avandaryl)                                                                • Not recommended for patients with NYHA
  glipizide/metformin (Metaglip)              PA           $57.60-$69.30           class III-IV cardiac status.
  glyburide/metformin (Glucovance)            PA           $19.20-$43.80        • Not recommended for patients with liver
  metformin/rosiglitazone                     PA           $64.89-$220.50          function tests greater than 2.5 times normal.
     (Avandamet)                                                                • May cause resumption of ovulation in
  pioglitazone/metformin (ActoPlus Met)       PA           $201.34                 premenopausal anovulatory women with
  repaglinide/metformin (Prandimet)           PA           $102.06                 insulin resistance.
  sitagliptin/metformin (Janumet)             PA           $180.18              Pregnancy/lactation:
  Miscellaneous                                                                 Insulin is the agent of choice during pregnancy
  colesevelam (Welchol), tablet               PA           $206.01              and lactation.
                                              (effective
                                              5/17/10)
# This is 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.
$
  This value represents the average monthly cost of the most commonly prescribed quantities as of 9/2009. Where
  applicable, cost represents that of an A rated generic equivalent (#).

May 3, 2010                                                           101
Therapeutic Class and Clinical Criteria Tables

Table 26. Oral Antidiabetic Agents (cont.)

II. Therapeutic Uses
    FDA-Approved, for example:
    • type-2 diabetes mellitus

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon diagnosis and/or requested medication (see below).

       Colesevelam (Welchol), tablet
       • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
       • Documentation of the following is required:
         o an adverse reaction or inadequate response to metformin therapy and at least one additional oral antidiabetic agent
           that does not require prior authorization when prescribed at therapeutic doses for an appropriate period of time.

       Fortamet, Glyset, Glumetza, Prandin, Starlix
       • Documentation of one of the following is required:
         o member has been stabilized on the medication for ≥ 90 days;
         o inadequate response to an agent that does not require prior authorization when prescribed at therapeutic doses
           for an adequate duration of time; or
         o an adverse reaction to an agent that does not require prior authorization.

         SmartPA: Claims for Fortamet, Glycet, Glumetza, Prandin, and Starlix will usually process at the pharmacy without a
         prior authorization request if the member has a history of MassHealth pharmacy claims for at least 90 days in the past
         120 days of the respective medication.†

         SmartPA: Claims for Glycet, Prandin, and Starlix will usually process at the pharmacy without a prior authorization
         request if the member has a history of MassHealth pharmacy claims for any oral antidiabetic medication that does not
         require prior authorization.†

       Januvia, Onglyza
       • Documentation of all of the following is required:
         o member is ≥ 18 years old;
         o an adverse reaction or inadequate response to at least one oral antidiabetic agent that does not require prior
           authorization when prescribed at therapeutic doses for an appropriate period of time; and
         o dose does not exceed 100 mg/day or 30 tablets/month and 100 mg/day (Januvia) or 5 mg/day (Onglyza).

       Combination Products
       • Documentation of one of the following is required:
         o treatment with stable doses of the separate agents for a minimum of three months; or
         o stabilized for at least three months on the combination product at the same.

         SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has a
         MassHealth history of pharmacy claims for 90 days (on separate agents or combination agents) in the past 120 days. †
†
    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: 5/2003                                                                  Last Revised Date: 11/2009




May 3, 2010                                                      102
Therapeutic Class and Clinical Criteria Tables

                                           MassHealth Evaluation Criteria
                                         Table 27. 5- HT3 Receptor Antagonists

 Drug Category: Gastrointestinal
 Medication Class/Individual Agent: Antiemetics/5-HT3 Receptor Antagonists
 I. Prior-Authorization Requirements
  Drug Name                                         PA Status           Clinical Notes
  dolasetron injection (Anzemet)                                        • Granisetron and ondansetron are FDA approved
  dolasetron tablet (Anzemet)                       PA                     for the prevention/treatment of postoperative,
  granisetron injection (Kytril #)                                         chemotherapy-induced, and radiation-induced
  granisetron solution 2 mg/10 ml (Kytril)          PA                     nausea and vomiting.
  granisetron tablet (Kytril #)                     PA                  • Anzemet is not FDA approved for the prevention
  granisetron transdermal system (Sancuso)          PA                     of radiation-induced nausea and vomiting.
  ondansetron 4 mg and 8 mg tablets                 PA > 15             • Anzemet is associated with more drug
     (Zofran #)                                     units/month            interactions than Kytril or Zofran.
  ondansetron 24 mg tablets (Zofran #)              PA > 5              • Anzemet has a cardiac warning and can prolong
                                                    units/month            the QTc interval.
  ondansetron injection (Zofran #)                                      • Dolasetron is FDA approved for
  ondansetron orally disintegrating tablet          PA                     prevention/treatment of postoperative and
     (Zofran ODT)                                                          chemotherapy-induced nausea and vomiting.
  ondansetron solution 4 mg/5 ml                    PA > 50             • Dolasetron should be administered with caution
     (Zofran #)                                     ml/month               in patients who have or may develop
  palonosetron (Aloxi)                                                     prolongation of cardiac conduction intervals,
                                                                           particularly QTc. These include patients with
                                                                           hypokalemia or hypomagnesmia, patients taking
                                                                           diuretics with potential for inducing electrolyte
                                                                           abnormalities, patients with congenital QT
                                                                           syndrome, patients taking antiarrythmic drugs or
                                                                           other drugs that lead to QT prolongation, and
                                                                           cumulative high-dose anthracycline therapy.

 # This is 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.

 II. Therapeutic Uses
     FDA-approved, for example:
     • chemotherapy induced nausea and vomiting (N/V)
     • radiation induced nausea and vomiting
     • postoperative nausea and vomiting

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

     Non-FDA approved, for example:
     • gastroparesis
     • HIV – associated nausea and vomiting
     • hyperemesis gravidarum

 III. Evaluation Criteria for Approval
      • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
      • Additional criteria may apply depending upon diagnosis (see below).
      • Criteria below do not apply to ondansetron ODT.




May 3, 2010                                                       103
Therapeutic Class and Clinical Criteria Tables



Table 27. 5- HT3 Receptor Antagonists (cont.)

      FDA-Approved Uses:
      Ondansetron exceeding quantity limits
      • Documentation of medical necessity for additional medication exceeding quantity limit is required.

         SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has a
         history of MassHealth medical claims for antineoplastic agents or radiation within the past 60 days.

      Non-FDA Approved Uses:
      Ondansetron exceeding quantity limits
      • Documentation of an inadequate response, adverse reaction, or contraindication to at least two other non-5-HT3
        receptor antagonists from at least two different classes (see list in Section IV) is required.

         SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has a
         history of MassHealth pharmacy claims for at least two different non-5-HT3 antiemetics from different classes
         when prescribed at therapeutic doses for an adequate duration.†

      Hyperemesis Gravidarum
      Ondansetron exceeding quantity limits
      • Documentation of the following is required:
        o an appropriate diagnosis; and
        o member has been on ondansetron previously.

         SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has a
         history of MassHealth pharmacy claims for hyperemesis gravidarum. †

      FDA-approved and non-FDA-approved uses
      Dolasetron and granisetron
      • Documentation of the following is required:
        o an appropriate diagnosis;
        o an inadequate response, adverse reaction, or contraindication to at least two other non-5-HT3 receptor antagonists
          from at least two different classes (see list in Section IV) is required; and
        o an inadequate response, adverse reaction, or contraindication to ondansetron.

      Granisetron transdermal system
      • Documentation of the following is required:
        o an appropriate diagnosis; and
        o medical necessity for transdermal formulation.

IV. Pediatric Patients
    • ondansetron (Zofran) is FDA-approved for chemotherapy-associated nausea and vomiting in children ≥ 6
      months old and for anesthesia associated nausea and vomiting in infants ≥ 1 month old.
    • promethazine and prochlorperazine are FDA- approved for use in children > two years old.

                                             Conventional Antiemetics
    Antihistamines               Prokinetic                Phenothiazines                      Anticholinergics
    dimenhydrinate               metoclopramide            prochlorperazine                    scopolamine
    diphenhydramine                                        promethazine                        trimethobenzamide
    hydroxyzine
    meclizine
†
 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: 12/2003                                                               Last Revised Date: 8/2009


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                                           MassHealth Evaluation Criteria
                                     Table 28. Dermatologic Agents – Antifungals

Drug Category: Dermatological
Medication Class/Individual Agent: Antifungals
I. Prior-Authorization Requirements
  Drug Name                                 PA Status                      Clinical Notes
  Allymines                                                                • Brand-name topical antifungal
  naftifine 1% C, G (Naftin)                PA                                products require prior
  terbinafine 1% S, G (Lamisil)             PA                                authorization.
  Benzylamine
  butenafine 1% C (Mentax)                  PA                             • Dermatophyte infections routinely
  Imidazoles                                                                 affect otherwise healthy
  clotrimazole * 1% C, O, S (Lotrimin #)                                     individuals.
  econazole 1% C (Spectazole #)
  ketoconazole 2% C, shampoo (Nizoral #)                                   • Immunocompromised patients are
  ketoconazole 2% G (Xolegel), F (Extina)   PA                               particularly susceptible to fungal
  miconazole * 2% C (Monistat #)                                             infections.
  miconazole 2% C (Monistat-Derm)           PA
  oxiconazole 1% C, L (Oxistat)             PA                             • Imidazoles are considered first-line
  sertaconazole 2% C (Ertaczo)              PA                               therapy for most dermatophyte
  sulconazole 1% C, S (Exelderm)            PA                               infections.
  combination products:
  clotrimazole/betamethasone C, O, L                                       • Products are usually applied once
     (Lotrisone #)                                                           or twice daily for two to four
  miconazole/zinc oxide O (Vusion)          PA                               weeks (depending on the location).
  Polyenes
                                                                           • Allymines are often reserved for
  nystatin C, O, powder (Mycostatin #,
                                                                             refractory and/or resistant
     Nilstat #, Pedi-Dri)
                                                                             dermatophyte infections.
  nystatin/triamcinolone C, O
  Other
                                                                           • Combination products may
  ciclopirox 1% shampoo; 0.77% G (Loprox) PA
                                                                             prolong treatment and delay
  ciclopirox 0.77% C, suspension (Loprox #)
                                                                             disease resolution.
  ciclopirox 8% nail lacquer (Penlac)       PA
  haloprogin (Halotin)                      PA                             • Onychomycosis requires 48 weeks
  tolnaftate *- 1% C, G, S, aerosol powder                                   of topical ciclopirox treatment.

                                                                           • Ciclopirox nail lacquer
                                                                             demonstrates a minimally better
                                                                             cure rate versus placebo.


C = cream, G = gel, L = lotion, O = ointment, S = solution, F = foam
# This is 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.
* The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth
   without prior authorization.

II. Therapeutic Uses
    FDA-approved, for example:
    • superficial tinea (fungal) infections
    • vulvovaginal candidiasis - vaginal formulations only
    • seborrheic dermatitis/dandruff – ciclopirox and ketoconazole only

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



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Table 28. Dermatologic Agents – Antifungals (cont.)

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply depending upon diagnosis (see below).

    Brand-name antifungals with no A-rated generics
    • Documentation of one of the following is required.
      o a clinically significant adverse event or inadequate response to at least two generic antifungals; or
      o a contraindication that supports the need for a specific product or dosage form of a nonreference antifungal.

       SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has a
       history of MassHealth pharmacy claims for two different generic antifungals (see Section I). †

    Brand-name antifungals with A-rated generics
    • Documentation of one of the following is required, including medical records (in addition to above criteria).
      o a clinically significant allergic response or adverse event to the generic product or its inactive ingredients; or
      o a clinically significant inadequate response to the generic product.
†
 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: 1/2005                                                                 Last Revised Date: 8/2006




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                                         MassHealth Evaluation Criteria
                                       Table 29. Allergy Agents: Ophthalmic
Drug Category: Allergy Agents
Medication Class/Individual Agents: Ophthalmic Allergy Agents

I. Prior-Authorization Requirements
 Drug Name                     Strength               PA Status    Clinical Notes
 Mast Cell Stabilizer /Antihistamine                               • Nonpharmacologic treatments, such as allergen
 azelastine (Optivar)          0.05%                  PA              avoidance, cold compress, and lubrication to
 epinastine (Elestat)          0.05%                  PA              remove the allergen, may provide relief.
 ketotifen (Alaway, generics) 0.025%
 olopatadine (Pataday,         0.1%                   PA           • Products containing vasoconstrictors may cause
    Patanol)                                                         rebound redness if used more frequently than
 Antihistamines                                                      the recommended treatment duration.
 bepotastine besilate          1.5%                   PA
    (Bepreve)                                                      • The dropper tip should not touch the eye in
 emedastine (Emadine)          0.05%                  PA             order to prevent contaminating the bottle.
 Corticosteroids
                                                                   • Remove contact lenses before instilling eye
 loteprednol (Alrex)           0.2%                   PA
                                                                     drops as some preservatives in ocular products
 Mast Cell Stabilizers
                                                                     may be absorbed by soft contact lenses.
 cromolyn sodium               4.0%
    (Crolom #)                                                     FDA-approved ages:
 lodoxamide (Alomide)          0.1%                   PA           • > 18 years of age: Alrex
 nedocromil (Alocril)          2.0%                   PA           • > 12 years of age: Livostin
 pemirolast (Alamast)          0.1%                   PA             > 6 years of age: Naphcon-A, Opcon-A, and
 Vasoconstrictor/Antihistamine                                       Visine-A
 naphazoline/pheniramine       0.025%, 0.3%                        • > 3 years old: Amalast, Alaway, Alocril,
    (Naphcon-A, Opcon-A,                                             Elestat, Emadine, Optivar, and Patanol
    Visine-A)                                                      • > 2 years old: Alomide
# This is 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.

II. Therapeutic Uses
    FDA-approved, for example:
    • Perennial or seasonal allergic conjunctivitis

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply depending upon requested medication (see below).

    Alrex
    • Documentation of all of the following is required.
      o an appropriate indication;
      o member is > 18 years of age;
      o an inadequate response or adverse reaction to at least one over-the counter combination vasoconstrictor and
        antihistamine product; and
      o an inadequate response or adverse reaction to ketotifen.




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Table 29. Allergy Agents: Ophthalmic
    Alamast, Alocril, Alomide, Bepreve, Elestat, Emadine, Optivar, Pataday, and Patanol for members >/= 7 years of
    age
    • Documentation of all of the following is required.
      o an appropriate indication;
      o an inadequate response or adverse reaction to at least one over-the-counter combination vasoconstrictor and
        antihistamine product; and
      o an inadequate response or adverse reaction to ketotifen.

    Alamast, Alocril, Alomide, Elestat, Emadine, Optivar, Pataday, or Patanol for members three to six years of age
    • Documentation of all of the following is required.
      o an appropriate indication; and
      o an inadequate response or adverse reaction to ketotifen.

    Alomide and Bepreve for members < 3 and > /= 2 years of age
    • Documentation of one of the following is required.
      o an appropriate indication.
†
 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: 4/2005                                                         Last Revised Date: 2/2010




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                                      MassHealth Evaluation Criteria
                                Table 30. Botulinum Toxins (Types A and B)
Drug Category: Muscle
Medication Class/Individual Agent: Neuromuscular Blockers

I. Prior-Authorization Requirements
Drug Name                                        PA Status                          Clinical Notes
abobotulinumtoxin A (Dysport)               PA                     FDA approved indication:
onabotulinumtoxin A (Botox)                 PA                     • Botox:
rimabotulinumtoxin B (Myobloc)              PA                       o Cervical dystonia in adults
                                                                     o Strabismus and blepharospasm associated
                                                                       with dystonia (including benign essential
                                                                       blepharospasm or VII nerve disorders) in
                                                                       patients 12 years or older
                                                                   • Myobloc:
                                                                     o Cervical dystonia in adults

                                                                   Additional information:
                                                                   • Due to the formation of antibodies, patients
                                                                     may develop resistance to Type A after
                                                                     repeated use. In these cases, Type B may be an
                                                                     alternative because antibodies to Type A and B
                                                                     do not cross-react.
                                                                   • Units of biological activity cannot be directly
                                                                     converted between Botulinum Types A and B.
                                                                   • There is also a difference in relative potencies
                                                                     between products distributed in North America
                                                                     and elsewhere.

                                                                   Contraindications:
                                                                   • Infection at the proposed injection site

                                                                   Warnings:
                                                                   • Recommended dose and frequency should not
                                                                     be exceeded. Risks with higher doses are
                                                                     unknown.
                                                                   • Hypersensitivity reactions
                                                                   • Preexisting neuromuscular disorders
                                                                   • Dysphagia
                                                                   • Human albumin (both products contain
                                                                     albumin)

II. Therapeutic Uses
    FDA-approved, for example:
    • Cervical dystonia in adults–Botox, Myobloc
    • Strabismus and blepharospasm associated with dystonia (including benign essential blepharospasm or VII nerve
      disorders) in patients 12 years or older–Botox

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




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Table 30. Botulinum Toxins (Types A and B) (cont.)

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see
       below).

    Strabismus blepharospasm associated with dystonia, focal dystonias, limb spasticity, and focal spasticity related
    to cerebral vascular accident
    • Documentation of all of the following is required:
      o an appropriate indication; and
      o appropriate dose stated for indication (child’s weight must be provided).

      SmartPA: Claims for Botox < 400 units and Myobloc < 20,000 units will usually process at the pharmacy without a
      prior authorization request if the member has a history of MassHealth medical claims for cerebral palsy and if
      MassHealth pharmacy claims indicate at least 70 days have passed since the last paid claim for Botox or Myobloc.†
†
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: 4/2001                                                                  Last Revised Date: 10/2007




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                                         MassHealth Evaluation Criteria
                             Table 31. Cerebral Stimulants and Miscellaneous Agents

Drug Category: Central Nervous System (CNS)
Medication Class/Individual Agents: Cerebral Stimulants
I. Prior-Authorization Requirements
  Drug Name                                 PA Status                     Clinical Notes
  Short-and Intermediate-acting Agents                                    Concurrent therapy with a short or intermediate-
  dexmethylphenidate (Focalin #)            PA > 90                       acting agent and a long-acting agent will also
                                            units/month                   require PA for quantities > 90 units/month (all
  dextroamphetamine (Dexedrine #,           PA > 90                       agents combined).
      Dexedrine Spansules, Dextrostat #)    units/month
  dextroamphetamine oral solution           PA > 450                      FDA-approved indications:
     (Procentra)                            ml/month                       • attention deficit hyperactivity disorder
  methamphetamine (Desoxyn)                 PA                                (ADHD)
  methylphenidate (Metadate ER #,           PA > 90                       Approved medications according to age:
  Methylin, Methylin ER, Ritalin #, Ritalin units/month                    • < 6 years old: short and intermediate acting
     SR #)                                                                    mixed amphetamine salts and
  methylphenidate oral solution (Methylin)  PA > 900                          dextroamphetamine, atomoxetine
                                            ml/month                       • > 6 years old: all cerebral stimulants,
  methylphenidate powder                    PA                                atomoxetine
  mixed amphetamine salts (Adderall #)      PA > 90
                                            units/month                   Narcolepsy:
  Long-acting agents                                                      • Short-or intermediate-acting mixed
  dexmethylphenidate (Focalin XR)           PA > 60                           amphetamine salts, dextroamphetamine, and
                                            units/month                       methylphenidate
  lisdexamfetamine (Vyvanse)                PA                            • Modafinil
  methylphenidate (Concerta, Metadate CD,   PA > 60
      Ritalin LA)                           units/month                   Precautionary use in:
  methylphenidate transdermal system        PA                             • advanced arteriosclerosis, symptomatic
      (Daytrana)                                                              cardiovascular disease, moderate to severe
  mixed amphetamine salts extended-release PA > 60                            hypertension, hyperthyroidism, glaucoma,
                                            units/month                       motor tics, Tourette’s syndrome, and seizure
                                                                              disorders
 mixed amphetamine salts extended-release           PA                     • psychologically agitated states, history of
  (Adderall XR)                                                               drug abuse
                                                                           • MAO inhibitor use within 14 days
 Miscellaneous
 atomoxetine (Strattera)                            PA                     At least 80% of children will respond to one of
 guanfacine extended-release (Intuniv)              PA                     the stimulants. The American Academy of
                                                                           Pediatrics recommends a trial of three different
 modafinil (Provigil): This product is not          PA
                                                                           stimulants before therapy is considered
    FDA-approved for ADHD.
                                                                           unsuccessful.
# This is 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.

II. Therapeutic Uses
     FDA-approved, for example:
     • attention deficit hyperactivity disorder (ADHD)
     • narcolepsy

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




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Table 31. Cerebral Stimulants and Miscellaneous Agents (cont.)
III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency for all stimulants
       prescribed.
     • Additional criteria may apply, depending upon requested medication (see below).

    Oral Agents
    • Documentation of medical necessity for greater than quantity limit is required (see list in Section IV for dose
      consolidation options).

    Adderral XR
    • Documentation, including medical records of one of the following is required:
      o a clinically significant allergic response or adverse event to mixed amphetamine salts or its inactive ingredients;
        or
      o a clinically significant inadequate response to mixed amphetamine salts.

    Vyvanse
    • Documentation of the following is required:
      o inadequate response or adverse reaction to at least one long-acting methylphenidate product, long-acting
        dexmethylphenidate, and a long-acting amphetamine product.

    Daytrana
    • Documentation that the member is 6-12 years of age and of one of the following is required:
      o medical necessity for transdermal formulation; or
      o inadequate response or adverse reaction to at least one long-acting methylphenidate product, long-acting
        dexmethylphenidate, and a long-acting amphetamine product;
      o quantity requested is < 30 tablets/30 days

    Intuniv
    • Documentation of the following is required:
      o member is > 6 years of age;
      o inadequate response to guanfacine; and
      o requested quantity is < 30 tablets/30 days.

    Strattera
    • Documentation of the following is required:
      o an adverse reaction or contraindication to methylphenidate and/or dextroamphetamine (e.g., amphetamines);
      o an inadequate response to methylphenidate and dextroamphetamine; or
      o the member (or immediate family member in household) has a history of substance abuse.
    • For adults, in addition to the above criteria, documentation must be provided regarding an inadequate response to a
      non-stimulant medication such as a tricyclic antidepressant or bupropion.

IV. Appendix

  Drug Name                                                                      Availability
 Short - and Intermediate-acting agents
 dexmethylphenidate (Focalin #)                                                  Tablet: 2.5, 5, 10 mg
 dextroamphetamine (Dexedrine #, Dexedrine Spansules, Dextrostat #)              Tablet: 5, 10 mg
 dextroamphetamine oral solution (Liquadd)                                       Solution: 5 mg/5 ml
 methamphetamine (Desoxyn)                                                       Tablet: 5 mg
 methylphenidate (Metadate ER #, Methylin, Methylin ER, Ritalin #,               Tablet: 5, 10, 20 mg
     Ritalin SR #)
 methylphenidate oral solution (Methylin)                                        Solution: 5 mg/5 ml, 10 mg/5 ml
 mixed amphetamine salts (Adderall #)                                            Tablet: 5, 7.5, 10, 12.5, 15, 20, 30 mg
 Long-acting Agents
 dexmethylphenidate (Focalin XR)                                                 Capsule: 5,10, 15, 20 mg
 lisdexamfetamine (Vyvanse)                                                      Capsule: 30, 50, 70 mg
 methylphenidate (Concerta)                                                      Tablet: 18, 27, 36, 54 mg
 methylphenidate (Metadate CD)                                                   Capsule: 10, 20, 30, 40, 50, 60 mg

May 3, 2010                                                  112
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Table 31. Cerebral Stimulants and Miscellaneous Agents (cont.)

methylphenidate (Ritalin LA)                                     Capsule: 10, 20, 30, 40 mg
methylphenidate transdermal system (Daytrana)                    Patch: 10, 15, 20, 30 mg
mixed amphetamine salts                                          Capsule: 5, 10, 15, 20, 25, 30 mg
mixed amphetamine salts (Adderall XR)                            Capsule: 5, 10, 15, 20, 25, 30 mg

Original Effective Date: 4/2006                                      Last Revised Date: 3/2010




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                                             MassHealth Evaluation Criteria
                                          Table 32. Serums, Toxoids, and Vaccines
Drug Category: Serums, Toxoids, and Vaccines
Medication Class/Individual Agents: Serums, Toxoids, and Vaccines
I. Prior-Authorization Requirements
Drug Name                                                      PA Status                           Clinical Notes
BCG vaccine (TheraCys, TICE BCG)                                              Administrative schedule:
diphtheria/tetanus toxoid vaccine1 (Decavac)                                  • For vaccinations that require a series of doses, the
diphtheria/tetanus toxoids/acellular pertussis vaccine 1                        time interval between each dose can be increased
  (Adacel, Boostrix, Daptacel, Infanrix, Tripedia)                              from the recommended schedule, but should not be
diphtheria/tetanus toxoids/acellular                                            decreased. The immunization series does not need to
  pertussis/haemophilus influenza                                               be restarted, regardless of the length of time from the
  b conjugate vaccine (TriHIBit)                                                last dose (exception: oral typhoid).
diphtheria/tetanus toxoids/acellular pertussis/hepatitis B,                   • If two live vaccines are administered separately, there
  recombinant/poliovirus, inactivated vaccine (Pediarix)                        should be at least an interval of 28 days in between.
diphtheria/tetanus toxoids/acellular pertussis/poliovirus,                    • Multiple inactivated vaccines can be administered at
  inactivated/haemophilus b conjugate vaccine 1                                 any time in relation to another.
  (Pentacel)
diphtheria/tetanus toxoids/acellular pertussis/poliovirus,                    Side effects:
  inactivated vaccine 1 (Kinrix)                                              • usually minor (e.g., slight fever, rash, or soreness at
hepatitis A inactivated 1 (Havrix, VAQTA)                                        the site of injection)
hepatitis A inactivated/hepatitis B recombinant vaccine                       • Serious reactions are extremely rare.
  (Twinrix)
hepatitis B recombinant vaccine (Engerix-B,                                   Safety:
  Recombivax)                                                                 • Thimerosal has been removed or reduced to trace
haemophilus b conjugate vaccine (ActHIB, HibTITER,                              amounts in almost all of the vaccines routinely
  PedvaxHIB)                                                                    recommended for children six years of age and
haemophilus b conjugate/hepatitis b vaccine (Comvax)                            younger.
herpes zoster vaccine (Zostavax)                              PA < 60 years   • Current scientific evidence does not support the
human papillomavrius bilvanet vaccine 1 (Cervarix)            PA < 10 years     hypothesis that vaccines have a causal link to autism.
                                                              and > 25
                                                              years           Contraindications:
human papillomavirus quadrivalent vaccine 1 (Gardasil)        PA < 9 years    • Serious allergic reaction to previous dose of vaccine
                                                              and > 26          or vaccine component
                                                              years
influenza virus vaccine, H1N1 (Influenza H1N1 Vaccine)                        Not Contraindications:
influenza virus vaccine, high dose 1 (Fluzone HD)             PA < 65 years   • mild acute illness with or without fever
influenza virus vaccine 1 (Fluarix, FluLaval, Fluvirin,                       • current antimicrobial therapy
   Fluzone)                                                                   • mild to moderate local reaction (e.g., swelling,
influenza virus vaccine, live, intranasal (FluMist)           PA > 1            redness, soreness)
                                                              dose/season     • low-grade or moderate fever after previous dose
Japanese encephalitis virus vaccine (Ixiaro, JE-VAX)                          • convalescent phase of illness
measles virus vaccine, live (Attenuvax)                                       • premature birth
measles/mumps/rubella vaccine 1 (M-M-R II)
measles/mumps/rubella/varicella virus vaccine 1                               Precautions:
   (ProQuad)                                                                  • moderate or severe acute illness with or without fever
meningococcal polysaccharide vaccine (Menomune-
   A/C/Y/W-135)                                                               Live Virus Vaccines (e.g., measles, mumps, rubella,
meningococcal conjugate vaccine 1 (Menactra)                                  varicella):
meningococcal quadrivalent vaccine                                            • Avoid use in immunocompromised patients.
   (Menveo-A/C/Y/W-135)                                                       • Administration should be deferred in the presence of
mumps virus vaccine (Mumpsvax)                                                   active infections or inactive, untreated tuberculosis.
pneumococcal conjugate vaccine 1 (Prevnar)                                    • Pregnancy should be avoided for three months
pneumococcal vaccine 1 (Pneumovax)                                               following vaccination.
pneumococcal 13-valent conjugate vaccine (Prevnar 13)
poliovirus vaccine, inactivated 1 (IPOL)                                      Report unexpected events after vaccinations to the
rabies virus vaccine (Imovax Rabies, RabAvert)                                Vaccine Adverse Event Reporting System (VAERS) at 1-
rotavirus vaccine 1 (Rotarix, RotaTeq)                                        800-822-7967.




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Table 32. Serums, Toxoids, and Vaccines (cont.)

Drug Name                                                               PA Status                                Clinical Notes
rubella virus vaccine (Meruvax II)
typhoid vaccine (Typhim Vi, Vivotif Berna)
varicella virus vaccine 1 (Varivax)
yellow fever vaccine (YF-VAX)
1
  Product may be obtained through the Massachusetts Department of Public Health (DPH). Please check with DPH for availability. MassHealth does not
pay for immunizing biologicals (i.e., vaccines) and tubercular (TB) drugs that are available free of charge through local boards of public health or through
the Massachusetts Department of Public Health without prior authorization (130 CMR 406.413(C)). However, for the 2009-2010 flu season, MassHealth
will pay pharmacies for seasonal flu vaccine serum without prior authorization if the vaccine is not available free of cost.


II. Therapeutic Uses
     FDA-approved, for example:
     • prevention of diseases caused by the human papillomavirus (HPV) types 6, 11, 16, and 18 – Gardasil
     • prevention of herpes zoster – Zostavax
     • prevention of influenza disease caused by influenza virus subtypes A and B – Flumist

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon requested medication (see below).

     Herpes zoster vaccine (Zostavax)
     • Documentation of the following is required:
       o an appropriate diagnosis; and
       o member is at least 60 years of age.

     Human papillomavirus bivalent vaccine (Cervarix)
     • Documentation of the following is required:
       o appropriate diagnosis;
       o member is female; and
       o member is 10-25 years of age.

     Human papillomavirus quadrivalent vaccine (Gardasil)
     • Documentation of the following is required:
       o an appropriate diagnosis; and
       o member is 9-26 years of age.

     Influenza virus vaccine, high dose
     • Documentation of the following is required:
       o an appropriate diagnosis; and
       o quantity of one dose per season; and
       o medical necessity for high dose in patients less than 65 years of age.

     Influenza virus vaccine, live, intranasal (FluMist) > 1 dose/season
     • Documentation of the following is required:
       o an appropriate diagnosis;
       o member is 2-8 years of age; and
       o documentation is provided that the member has not been previously vaccinated with the live intranasal virus vaccine
         or has only received one dose in their first year of vaccination.

Original Effective Date: 9/2003                                                                                     Last Revised Date: 2/2010




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                                       MassHealth Evaluation Criteria
                            Table 33. Selective Aldosterone Receptor Antagonists

Drug Category: Cardiovascular
Medication Class/Individual Agent: Diuretic, Potassium Sparing
I. Prior-Authorization Requirements
  Drug Name                                                    PA Status
  eplerenone (Inspra)                                          PA
  spironolactone

II. Therapeutic Uses
    FDA-approved, for example:
    • congestive heart failure post-myocardial infarction
    • hypertension

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply depending upon diagnosis and/or requested medication (see below).

    Hypertension
    • Documentation of all of the following is required:
      o an adverse reaction, inadequate response or contraindication to a thiazide diuretic and spironolactone; and
      o medical necessity for a selective aldosterone receptor antagonist versus less costly antihypertensive
        agents such as generic diuretics, beta blockers, ACE inhibitors, and calcium channel blockers.

    Congestive heart failure post-myocardial infarction
    • Documentation of an adverse reaction, inadequate response or contraindication to spironolactone is required.

      SmartPA: Claims will usually process at the pharmacy without a prior authorization request if the member has a
      history of MassHealth medical claims for heart failure and a history of MassHealth pharmacy claims for
      spironolactone.†
†
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: 4/2003                                                 Last Revised Date: 9/2006




May 3, 2010                                                 116
Therapeutic Class and Clinical Criteria Tables

Table 34 – Antibiotics: Ophthalmic
Drug Name                                                     PA Status         Clinical Notes
azithromycin 1% S (AzaSite)                                   PA                •    Mild bacterial conjunctivitis may be self-limited and resolve
bacitracin O                                                                         spontaneously in immune-competent adults
besifloxacin (Besivance)                                      PA
                                                                                •    Duration, recurrence rate, and morbidity associated with
ciprofloxacin 0.3% O (Ciloxan)                                PA
                                                                                     most common types of bacterial conjunctivitis may be
ciprofloxacin 0.3% S (Ciloxan #)                                                     decreased with topical antibacterial therapy.
erythromycin 0.5% O
gatifloxacin 0.3% S (Zymar)                                   PA                •    Treatment should last 5 to 7 days for bacterial conjunctivitis
gentamicin 0.3% O (generics), S (Gentak #, Genoptic #)                               and 3 to 5 days for corneal ulcers.
levofloxacin 1.5% S (Iquix)                                   PA
                                                                                •    Ointment may blur vision for up to 20 minutes but are
levofloxacin 0.5% S (Quixin)                                  PA
                                                                                     preferred for corneal ulcers because it acts as a lubricant.
moxifloxacin 0.5% S (Vigamox)                                 PA
ofloxacin 0.3% S (Ocuflox #)                                                    •    Contact lens wearers may require a fluroquinolones due to
sulfacetamide 10% O (generics), S (Bleph-10 #,                                       the high incidence of pseudomonas infection.
   Sulf-10 #)
tobramycin 0.3% O (Tobrex)                                    PA                •    Tobramycin/dexamethasone and
tobramycin 0.3% S (Tobrex #)                                                         sulfacetamide/flurometholone carry indications for pediatric
trimethoprim sulfate/polymyxin B S (Polytrim #)                                      use.
Combination Products
fluorometholone/sulfacetamide (FML-S)
loteprednol/tobramycin S (Zylet)
neomycin/bacitracin/polymixin B/hydrocortisone
neomycin/polymixin B/dexamethasone O, S
   (Maxitrol #)
neomycin/polymyxin B/hydrocortisone S
    (Cortisporin#)
neomycin/polymixin B/ prednisolone S (Poly-Pred )
prednisolone/gentamicin O, S (Pred-G)
sulfacetamide/prednisolone O, S (Blephamide #)
tobramycin/dexamethasone O, S (Tobradex #)
O=ointment, S=solution

# This is 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.




May 3, 2010                                                        117
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Table 35 – Antibiotics: Oral
Drug Name                                        PA       Average                              Clinical Notes
                                                Status    Cost per
                                                          Claim $
Aminoglycosides                                                        • Antibacterial resistance is an increasing public health
neomycin *                                               $61.59          concern. Factors leading to resistance include overuse of
paromomycin                                              $85.20          antibiotics, improper use by patients, and incorrect
Cephalosporins                                                           diagnosis.
cefaclor                                                 $26.34        • Keflex (cephalexin) capsules are available in 250, 500,
cefaclor extended-release                       PA       $74.00          and 750-mg strengths. The 250-mg and 500-mg capsules
cefadroxil suspension (Duricef #), cefadroxil            $14.57 (#)      are available generically and are significantly less costly.
   500 mg                                                                Prior authorization is required for Keflex 750-mg
cefadroxil 1 gram tablet                        PA       $82.00          capsules.
cefdinir (Omnicef #)                                     $127.08 (#)   • Ciprofloxacin extended-release tablet is a once-a-day
cefditoren (Spectracef)                                  $167.30         formulation that is FDA-approved for the treatment of
cefixime (Suprax)                                        $113.34         urinary tract infections. Studies show safety and efficacy
cefpodoxime (Vantin #)                                   $93.78 (#)      to be similar to immediate-release ciprofloxacin.
cefprozil (Cefzil #)                                     $66.70 (#)      Likewise, half-life, AUC, and time to peak plasma
ceftibuten (Cedax)                                       $106.30         concentration were similar between equivalent daily
cefuroxime (Ceftin#)                                     $15.93 (#)      doses of ciprofloxacin extended release and immediate-
cephalexin 250 mg, 500 mg (Keflex #)                     $11.99 (#)      release products. Prior authorization is required for
cephalexin 750 mg (Keflex)                      PA       $52.40          ciprofloxacin extended-release tablets.
Fluoroquinolones                                                       • Adoxa and Oracea are brand-name doxycycline products.
ciprofloxacin (Cipro#)                                   $2.35 (#)       Adoxa is marketed for the treatment of acne. Oracea is
ciprofloxacin extended-release (Cipro XR #,     PA       $11.30 (#)      marketed for the treatment of rosacea. Oracea has not
   Proquin XR)                                                           been evaluated in the treatment or prevention of infection.
gemifloxacin (Factive)                                   $118.65
                                                                       • Because doxycycline is available generically in a number
levofloxacin (Levaquin)                                  $128.55
                                                                         of strengths, Adoxa, Oracea, and Monodox 75- mg
moxifloxacin (Avelox)                                    $143.10         capsule require prior authorization.
norfloxacin (Noroxin)                                    $107.58
ofloxacin (Floxin #)                                     $85.41 (#)    • Solodyn is an extended-release minocycline product
Macrolides                                                               indicated for moderate to severe acne. Generic immediate
azithromycin (Zithromax #, Zmax)                         $11.97 (#)      release formulations are available without prior
                                                                         authorization.
clarithromycin (Biaxin #)                                $21.93 (#)
clarithromycin extended-release (Biaxin XL)     PA       $68.32        • Clindamycin capsules are available in 150-mg and 300-
erythromycin (E-mycin #, Ery-tab, PCE                    $10.31          mg strengths. Due to a considerable cost difference, the
   Dispertab)                                                            150-mg capsule is available without prior authorization
erythromycin ethylsiccinate (Eryped #)                   $11.19 (#)      while the 300-mg strength requires PA.
telithromycin (Ketek)                           PA       $100.80       • Metronidazole is available generically in 250-mg, and
Penicillins                                                              500-mg tablets, and 375-mg capsules. Flagyl ER 750-mg
amoxicillin (Amoxil#, Trimox #)                          $4.24 (#)       tablets are not available generically. Due to a considerable
amoxicillin/clavulanate (Augmentin #)                    $36.45 (#)      cost difference, metronidazole 375-mg capsules and
amoxicillin extended-release (Moxatag)          PA       $78.80          Flagyl ER 750-mg tablets require prior authorization.
amoxicillin/clavulanate extended-release        PA       $217.22       • Zyvox (linezolid) is FDA approved for the treatment of
   (Augmentin XR)                                                        gram-positive coccal infections including methicillin-
ampicillin (Omnipen#, Principen #)                       $8.26 (#)       resistant Staphylococcus aureus (MRSA).
dicloxacillin (Dynapen #)                                $26.20 (#)    • The CDC recommends that clinicians reserve Zyvox for
penicillin V (Veetids #)                                 $7.68 (#)       more severe infections after consultation with an
Sulfonamides                                                             infectious disease specialist or for those patients who
sulfadiazine                                             $182.79         have not responded to other antibiotics.
sulfamethoxazole/trimethoprim (Bactrim #,                $3.63 (#)
                                                                       • Community acquired MRSA has responded to a number
   Septra #, Sulfatrim)
                                                                         of other antibiotics including doxycycline, clindamycin,
sulfisoxazole (Gantrisin)                                $7.86
                                                                         minocycline, and TMP/sulfamethoxazole. Vancomycin
                                                                         continues to be first line treatment for hospital-acquired
                                                                         MRSA infections.
                                                                       • Augmentin XR, clarithromycin extended-release, and
                                                                         cefaclor extended-release are available as generic
                                                                         immediate release formulations. The generic immediate
                                                                         release formulations are available without prior
                                                                         authorization.



May 3, 2010                                                      118
Therapeutic Class and Clinical Criteria Tables

Table 35 – Antibiotics: Oral (cont.)
Drug Name                                           PA        Average                              Clinical Notes
                                                   Status     Cost per
                                                              Claim $
Tetracyclines                                                               • Cefadroxil 1 gram tablet requires prior authorization.
demeclocycline (Declomycin #)                                $402.27 (#)      Cefadroxil 500 mg is a less costly alternative and is
doxycycline (Monodox#, Periostat#,                           $2.34 (#)        available without prior authorization.
  Vibramycin #)                                                             • Ketek (telithromycin) requires prior authorization and
doxycycline (Adoxa, Oracea)                        PA        $287.70          there are clinically appropriate alternatives available
doxycycline (Doryx)                                PA        $391.84          without prior authorization.

minocycline (Dynacin #, Minocin #)                           $36.54 (#)
minocycline extended-release (Solodyn)             PA        $564.60
tetracycline (Sumycin #)                                     $5.50 (#)
Miscellaneous Anti-infective Agents
clindamycin 75 mg, 150-mg capsule (Cleocin#)       PA        $11.92 (#)

clindamycin 300-mg capsule                         PA        $61.53
dapsone                                                      $35.12
fosfomycin (Monurol)                                         $39.35
linezolid (Zyvox) suspension, tablet               PA        $2,146.05
metronidazole 250 mg, 500 mg (Flagyl #)                      $3.42 (#)
metronidazole 375-mg capsule                       PA        $51.94
metronidazole extended-release (Flagyl ER)         PA        $74.76
nitrofurantoin (Furadantin, Macrobid #,                      $11.14
   Macrodantin #)
rifaximin (Xifaxan)                                PA        $864.11
trimethoprim (Primsol, Proloprim #)                          $10.78 (#)
vancomycin (Vancocin) capsule                      PA        $1,517.71
# This is 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.
* The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth
  without prior authorization.
$
  This value represents the average cost per claim of the most commonly prescribed quantities as of 9/2009. Where applicable, cost
  represents that of an A rated generic equivalent (#).




May 3, 2010                                                        119
Therapeutic Class and Clinical Criteria Tables

                                    MassHealth Evaluation Criteria
                              Table 36. Alcohol and Drug-Cessation Agents
Drug Category: Central Nervous System Agents
Medication Class/Individual Agent: Alcohol/Drug Cessation Agents

I. Prior-Authorization Requirements
Drug Name                                     PA Status                             Clinical Notes
acamprosate (Campral)                                           Suboxone and Subutex
buprenorphine (Subutex)                  PA                     Prescribing:
buprenorphine/naloxone (Suboxone)        PA                     • The Drug Addiction and Treatment Act of 2000
   > 32 mg/day                                                     (DATA 2000) allows specially trained
buprenorphine/naloxone (Suboxone)        PA > 90 days/             physicians to use Schedules III, IV, and V
   > 24 and < 32 mg/day                  treatment                 medicines to treat opioid dependence. If a
buprenorphine/naloxone (Suboxone) > 16   PA > 180 days/            qualified physician (i.e., MD or DO only)
   and < 24 mg/day                       treatment                 fulfills specific training requirements and
buprenorphine/naloxone (Suboxone) < 16                             provides access to psychosocial therapy, he/she
   mg/day                                                          will be able to treat either 30 or 100 patients
disulfiram (Antabuse)                                              depending on the date when the physician
naloxone                                                           submitted first notification of intent. For more
naltrexone (Revia #)                                               information call 1-866-287-2728 or visit
naltrexone injection (Vivitrol)          PA                        www.buprenorphine.samhsa.gov.

                                                                FDA Approved Uses:
                                                                • Suboxone and Subutex are Schedule III
                                                                  controlled substances approved for treatment of
                                                                  opioid dependence. These agents are not FDA-
                                                                  approved for pain management. The injectable
                                                                  form of buprenorphine (i.e., brand and generic
                                                                  Buprenex) is approved for treating moderate-to-
                                                                  severe pain at doses between 0.3-0.6 mg every
                                                                  6 hours. The elimination half-life of
                                                                  buprenorphine is 37 hours.

                                                                Additional information:
                                                                • Diversion/misuse of Subutex by injection may
                                                                  occur in members who are physically
                                                                  dependent on opioids or taking full agonist
                                                                  opioids because withdrawal is less likely to
                                                                  occur in these members. Diversion/misuse of
                                                                  Suboxone or Subutex by injection may occur in
                                                                  buprenorphine-maintained members due to a
                                                                  desired acute agonist effect caused by an
                                                                  inadequate dose of naloxone (i.e., no antagonist
                                                                  effect).

                                                                Vivitrol
                                                                • Vivitrol is FDA-approved for the treatment of
                                                                  alcohol dependence in patients who are
                                                                  abstinent at treatment initiation.




May 3, 2010                                               120
Therapeutic Class and Clinical Criteria Tables

Table 36. Alcohol and Drug-Cessation Agents (cont.)

Drug Name                                              PA Status                             Clinical Notes
                                                                         Contraindications:
                                                                         • acamprosate: those who have had a
                                                                            hypersensitivity reaction to acamprosate in the
                                                                            past and severe renal impairment (creatinine
                                                                            clearance <30 ml/min)
                                                                         • buprenorphine: hypersensitivity to
                                                                            buprenorphine
                                                                         • buprenorphine/naloxone: hypersensitivity to
                                                                            buprenorphine and/or to naloxone
                                                                         • disulfiram: recent use of metronidazole,
                                                                            paraldehyde, alcohol, or alcohol-containing
                                                                            products, myocardial disease or coronary
                                                                            occlusion, psychoses and hypersensitivity to
                                                                            disulfiram or other thiuram derivatives
                                                                         • naltrexone: current use of or dependence on
                                                                            opioids, acute withdrawal, those who have
                                                                            failed a naloxone challenge test or have a
                                                                            positive urine screen for opioids, acute
                                                                            hepatitis, or liver failure and sensitivity to
                                                                            naltrexone or any component of the product

                                                                         Warnings/Precautions:
                                                                         • acamprosate: does not eliminate or diminish
                                                                           withdrawal symptoms
                                                                         • buprenorphine: acute alcoholism, adrenal
                                                                           cortical insufficiency, delirium tremens, CNS
                                                                           depression, respiratory depression, head injury,
                                                                           dependence, large doses of narcotics,
                                                                           hypotension
                                                                         • buprenorphine/naloxone: respiratory
                                                                           depression, CNS depression, CNS depressants,
                                                                           acute abdominal conditions, acute alcoholism,
                                                                           adrenal cortical insufficiency, concomitant
                                                                           CYP3A4 inhibitors, delirium tremens, elderly
                                                                           or debilitated patients, dependence, hepatitis,
                                                                           allergic reactions, head injury and increased
                                                                           intracranial pressure, prostatic hypertrophy or
                                                                           urethral stricture and opioid withdrawal effects
                                                                         • disulfiram: diabetes mellitus, disulfiram-
                                                                           alcohol reaction, hepatic dysfunction;
                                                                           hypothyroidism, epilepsy, cerebral damage,
                                                                           renal impairment, rubber contact dermatitis and
                                                                           environmental or occupational exposure to
                                                                           ethylene dibromide or its vapors
                                                                         • naltrexone: hepatotoxicity, hepatic impairment,
                                                                           history of suicide attempts, with or without
                                                                           depression, symptoms of withdrawal
#This is 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.




May 3, 2010                                                        121
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Table 36. Alcohol and Drug-Cessation Agents (cont.)

II. Therapeutic Uses
    FDA-approved, for example:
    • alcohol dependence (acamprosate, disulfiram, naltrexone)
    • opioid dependence (naloxone, Suboxone, Subutex)

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see
       below).

    Subutex < 24 mg/day
    • Documentation of all of the following is required:
      o rationale for prescribing Subutex instead of Suboxone;
      o complete treatment plan; and
      o request is submitted by a licensed Subutex/Suboxone prescriber (i.e., DEA must begin with an “X”).

    Subutex > 24 mg/day to < 32 mg/day
    • Documentation of all of the following is required:
      o rationale for prescribing Subutex instead of Suboxone;
      o rationale for high dose (requires medical records);
      o complete treatment plan, including a specific taper schedule; and
      o request is submitted by a licensed Subutex/Suboxone prescriber (i.e., DEA must begin with an “X”).

    Suboxone > 16 mg/day to < 24 mg/day for > 180 days
    • Documentation of all of the following is required:
      o rationale for high dose (requires medical records);
      o complete treatment plan; and
      o request is submitted by a licensed Subutex/Suboxone prescriber (i.e., DEA must begin with an “X”).

    Suboxone > 24 mg/day to < 32 mg/day for > 90 days
    • Documentation of all of the following is required:
      o rationale for high dose (requires medical records);
      o complete treatment plan; and
      o request is submitted by a licensed Subutex/Suboxone prescriber (i.e., DEA must begin with an “X”).

    Vivitrol
    • Documentation of all of the following is required:
      o appropriate diagnosis;
      o medical necessity for the once-monthly injectable product including rationale why it would offer a therapeutic
        advantage over oral naltrexone; and
      o an inadequate response, adverse reaction, or contraindication to oral naltrexone.

Original Effective Date: 5/2007                                                              Last Revised Date: 11/2009




May 3, 2010                                                 122
Therapeutic Class and Clinical Criteria Tables

                                      MassHealth Evaluation Criteria
                                      Table 37. Palivizumab (Synagis)
Drug Category: Respiratory Tract Agents
Medication Class/Individual Agent: Individual Agent: Immunologic Agents

I. Prior-Authorization Requirements
Drug Name                                      PA Status                            Clinical Notes
palivizumab (Synagis)                     PA                     Synagis Evaluation Criteria:
                                                                 • Evaluation criteria are based on
                                                                    recommendations from the Massachusetts
                                                                    Chapter of the American Academy of Pediatrics
                                                                    (AAP) and 2009 Report of the Committee on
                                                                    Infectious Diseases and are supported by the
                                                                    AAP practice guidelines “Diagnosis and
                                                                    Management of Bronchiolitis”
                                                                 • Synagis is intended for the prophylaxis of
                                                                    respiratory syncytial virus (RSV) and not for
                                                                    the treatment of patients currently infected with
                                                                    RSV
                                                                 • In most regions of the northern hemisphere, the
                                                                    first dose of palivizumab should be
                                                                    administered at the beginning of November and
                                                                    the last dose should be administered at the
                                                                    beginning of March, which will provide
                                                                    protection into April.

                                                                 Safety and Efficacy of Synagis Established in:
                                                                 • infants with bronchopulmonary dysplasia
                                                                    (BPD)
                                                                 • infants with a history of premature birth (<35
                                                                    weeks gestational age)
                                                                 • children with hemodynamically significant
                                                                    congenital heart disease (CHD)

                                                                 AAP Policy Statement:
                                                                 • Infants 24 months of age or younger with
                                                                   congenital heart disease (CHD) who are NOT
                                                                   at increased risk from RSV and generally
                                                                   should not receive Synagis include the
                                                                   following:
                                                                    o infants and children with hemodynamically
                                                                        insignificant heart disease (e.g., secundum
                                                                        atrial septal defect, small ventricular septal
                                                                        defect, pulmonic stenosis, uncomplicated
                                                                        aortic stenosis, mild coarctation of the
                                                                        aorta, and patent ductus arteriosus)
                                                                    o infants with lesions adequately corrected
                                                                        by surgery unless they continue to require
                                                                        medication for congested heart failure
                                                                    o infants with mild cardiomyopathy who are
                                                                        not receiving medical therapy




May 3, 2010                                                123
Therapeutic Class and Clinical Criteria Tables

Table 37. Palivizumab (Synagis) (cont.)

Drug Name                                         PA Status                          Clinical Notes
                                                                    Additional information:
                                                                    • RSV outbreak is defined by the National
                                                                      Respiratory and Enteric Virus Surveillance
                                                                      System (NREVSS) as the first of 2 consecutive
                                                                      weeks when 50% of participating laboratories
                                                                      report RSV detection and the mean percentage
                                                                      of positive specimens is >10%.

II. Therapeutic Uses
    FDA-approved, for example:
    • prevention of serious lower respiratory tract disease caused by respiratory syncytial virus (RSV) in pediatric patients at
      high risk of severe RSV disease

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see
       below).

    Chronic lung disease (CLD) or bronchopulmonary dysplasia (BPD)
    • Documentation of all of the following is required:
      o member is < 24 months of age at the start of the RSV season;
      o diagnosis of chronic lung disease (CLD) or bronchopulmonary dysplasia (BPD); and
      o the need for on-going therapy for the CLD or BPD within the last six months prior to the start of the RSV season;
        and/or radiographic changes which are consistent with CLD or BPD.

    Prematurity
    • Documentation of one of the following is required:
      o member is < 12 months of age at start of the RSV season with a gestational age of < 28 weeks, 6 days;
      o member is < 6 months of age at start of the RSV season with a gestational age of 29 weeks, 0 days–31 weeks, 6
        days; or
      o member is < 3 months of age at start of the RSV season with a gestational age of 32 weeks, 0 days–34 weeks, 6 days
        and has at least one additional risk factor as defined by the American Academy of Pediatrics (AAP).

    Congenital heart disease (CHD)
    • Documentation of the following is required:
      o member is 24 months of age or younger at start of the RSV season; and
      o hemodynamically significant congenital heart disease (CHD) with one of the following criteria:
          moderate to severe pulmonary hypertension;
          receiving medication(s) to control congestive heart failure; or
          cyanotic heart disease.

Original Effective Date: 4/2001                                                                 Last Revised Date: 11/2009




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                                            MassHealth Evaluation Criteria
                                         Table 38. Antiretroviral/AIDS Therapy
Drug Category: Anti-infectives
Medication Class/Individual Agents: Antiretroviral/AIDS therapy
I. Prior-Authorization Requirements
  Drug Name                                       PA Status              Clinical Notes
  CCR5 Antagonists                                                       CCR-tropic HIV-1 Trofile Assay:
  maraviroc (Selzentry)                           PA                     • Currently, the Trofile co-receptor test assay is the
  Fuzeon Inhibitors                                                          only diagnostic test that identifies CCR5-tropic
  enfuvirtide (Fuzeon)                                                       HIV-1 infection.
  Integrase Strand Transfer Inhibitor                                    • A positive test result is required for the approval of
  raltegravir (Isentress)                                                    maraviroc.
  Nucleoside Reverse Transcriptase Inhibitors (NRTI)
  abacavir (Ziagen)                                                      Maraviroc Black Box Warning:
  didanosine (Videx)                                                     • Hepatotoxicity has been reported with maraviroc
  emtricitabine (Emtriva)                                                   use. Evidence of a systemic allergic reaction (e.g.,
  lamivudine (Epivir)                                                       pruritic rash, eosinophilia or elevated IgE) prior to
  stavudine (Zerit)                                                         the development of hepatotoxicity may occur.
  zidovudine (Retrovir #)                                                   Patients with signs or symptoms of hepatitis or
                                                                            allergic reaction following use of maraviroc should
  Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
                                                                            be evaluated immediately.
  delavirdine (Rescriptor)
  efavirenz (Sustiva)
                                                                         Maraviroc Warnings:
  etravirine (Intelence)
                                                                         • Caution should be used when administering
  nevirapine (Viramune)                                                     maraviroc to patients with preexisting liver
  Nucleoside Reverse Transcriptase Inhibitors (NtRTI)                       dysfunction or who are co-infected with viral
  tenofovir (Viread)                              PA > 30                   hepaitiis B or C.
                                                  units/month            • More cardiovascular events including myocardial
  Protease Inhibitors (PI)                                                  ischemia and/or infarction were observed in patients
  atazanavir (Reyataz)                                                      who received maraviroc. Use with caution in
  darunavir (Prezista)                                                      patients at increased risk of cardiovascular events.
  fosamprenavir (Lexiva)
  indinavir (Crixivan)
  lopinavir/ritonavir (Kaletra)
  nelfinavir (Viracept)
  ritonavir capsule (Norvir)
  ritonavir tablet (Norvir)                       PA
  saquinavir (Invirase)
  tipranavir (Aptivus)
  Combination Products
  abacavir/lamivudine (Epzicom)
  abacavir/lamivudine/zidovudine (Trizivir)
  efavirenz/emtricitabine/tenofovir (Atripla)
  emtricitabine/tenofovir (Truvada)
  lamivudine/zidovudine (Combivir)
  Assays
  CCR5-tropic HIV-1 Trofile Assay                 PA

II. Therapeutic Uses
     FDA-approved, for example:
     • Use in combination with other antiretroviral agents for the treatment of HIV-1 infection (Norvir tablet).
     • Use in combination with other antiretroviral treatments in adults infected with only CCR5-tropic HIV-1 detectable, who have
       evidence of viral replication and HIV-1 strains resistant to multiple antiretroviral agents (Selzentry).

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).



May 3, 2010                                                       125
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Table 38. Antiretroviral/AIDS Therapy (cont.)

    CCR5-tropic HIV-1 Trofile Assay:
    • Documentation of the following is required:
      o member > 16 years old; and
      o concurrent antiretroviral therapy (with at least two other HIV antiretrovirals); and
      o treatment failure of combination antiretroviral therapy as evident by viral replication with at least one agent from
        three of the four antiretroviral drug classes (NRTI, NNRTI, PI, enfurviride); or
      o resistance or intolerance to at least one agent from three of the four antiretroviral classes listed above; or
      o initiation therapy in treatment naïve patients in combination with other agents.

    Norvir tablet (ritonavir)
    • Documentation of the following is required:
      o member does not have access to refrigeration.

    Selzentry (maraviroc):
    • Documentation of the following is required:
      o member > 16 years old;
      o concurrent antiretroviral therapy (with at least two other HIV antiretrovirals);
      o Trofile Assay result indicating CCR5 tropism; and
      o treatment failure of combination antiretroviral therapy as evident by viral replication with at least one agent from
        three of the four antiretroviral drug classes (NRTI, NNRTI, PI, enfurviride); or
      o resistance or intolerance to at least one agent from three of the four antiretroviral classes listed above; or
      o initiation therapy in treatment naïve patients in combination with other agents.

    Viread (tenofovir)
    • Documentation of the following is required:
      o medical necessity for additional medication exceeding the quantity limits.

Original Effective Date: 9/2007                                                                Last Revised Date: 2/2010




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                                           MassHealth Evaluation Criteria
                                          Table 39. Neuraminidase Inhibitors
Drug Category: Anti-infectives
Medication Class/Individual Agents: Antiviral/Influenza

I. Prior-Authorization Requirements
  Drug Name           PA Status                                 Clinical Notes
  oseltamivir         PA all quantities (June 1st –             Prior Authorization Quantity Limits:
    (Tamiflu)         September 30 th)                          • June 1st – September 30 th :
                                                                  o Oseltamivir capsules – PA for all quantities
                         PA on requests exceeding quantity        o Oseltamivir suspension – PA for all quantities
                         limits listed (October 1st – May         o Zanamivir – PA for all quantities
                         31st)                                  • October 1st – May 31st :
    peramavir H                                                   o Oseltamivir 30 mg capsules – PA > 20 capsules/month
    zanamivir            PA all quantities (June 1st –              and > 40 capsules/season
      (Relenza)          September 30 th)                         o Oseltamivir 45 mg or 75 mg capsules – PA
                                                                    > 10 capsules/month and > 20 capsules/season
                         PA on requests exceeding quantity        o Oseltamivir suspension – PA >75 mL/month and 150
                         limits listed (October 1st – May           mL/season
                         31st)                                    o Zanamivir – PA > 20 inhalations/month or 40
                                                                    inhalations/season

                                                                Contraindications:
                                                                 Zanamivir: Hypersensitivity to any component of the
                                                                 product including lactose (milk proteins)

                                                                   Warnings:
                                                                   • Concurrent use of influenza virus vaccine live intranasal
                                                                     (FluMist) within 48 hours after administration of or
                                                                     within two weeks before administration of neuraminidase
                                                                     inhibitors
                                                                   • Zanamivir: airway disease (e.g., COPD, asthma)
                                                                   • Oseltamivir: hereditary fructose intolerance (with
                                                                     suspension), renal impairment, self-injury and delirium,
                                                                     and serious skin reactions.
H
    This drug is available only in an inpatient hospital setting. MassHealth does not pay for this drug to be dispensed through
    the retail pharmacy or physician’s office.

II. Therapeutic Uses
     FDA-approved, for example:
     • Influenza Type A and B (oseltamivir > 1 year of age*; zanamivir > 7 years of age)
     • Prophylaxis of Influenza Type A and B (oseltamivir > 1 year of age; zanamivir > 5 years of age)
     • The Centers for Disease Control have issued emergency use authorization for children < 1 year old.

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).
     Prophylaxis
     Flu season prescriptions exceeding quantity limits and any quantity from June 1st – September 30th:
     • Documentation of the following is required:
       o member with likely exposure to others infected with influenza and are at high risk for developing influenza-related
         complications, due to one or more risk factors:
            age > 65 years or < 5 years;
            residence in a nursing home or chronic care facility;
            chronic pulmonary disease (e.g. asthma, COPD);
May 3, 2010                                                    127
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Table 39. Neuraminidase Inhibitors (cont.)

          chronic cardiovascular disease (not hypertension);
          chronic metabolic disease (e.g. diabetes);
          renal or hepaticdys function;
          hematologicial disorders (e.g. sickle cell);
          pregnant women;
          neurologic or neuromuscular disorders;
          immunosuppression (e.g. HIV, chemotherapy, steroids, etc.);
          long-term aspirin therapy < 19 years of age); or
          health care workers for individuals at high risk of serious complications of influenza infection during an
          institutional outbreak (may be considered for prophylaxis); and
          member is five years of age or older (Relenza).

    Treatment
    Flu season prescriptions exceeding quantity limits and any quantity from June 1st – September 30th:
    • Documentation of the following is required:
      o member with confirmed, probable, or suspected influenza and is at high risk for developing influenza-related
        complications, due to one or more risk factors listed above; or
      o member is at high risk for developing serious influenza-related complications and is within 48 hours of illness onset;
        and
      o member is seven years of age or older (Relenza).

Original Effective Date: 9/2003                                                               Last Revised Date: 11/2009




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                                         MassHealth Evaluation Criteria
                                         Table 40. Leukotriene Modifiers

Drug Category: Respiratory Tract Agents
Medication Class/Individual Agents: Leukotriene Modifiers

I. Prior-Authorization Requirements
  Drug Name                                PA Status                  Clinical Notes
  montelukast (Singulair)                  PA > 16 years; PA          Contraindications:
                                           (effective 5/17/10)        • All agents: hypersensitivity to any component
 zafirlukast (Accolate)                    PA > 16 years; PA          • Zileuton:
                                           (effective 5/17/10)          o Active liver disease
 zileuton extended-release (Zyflo CR)      PA                           o Persistent liver enzyme elevations three or
                                                                          more times the upper limit of normal

                                                                      Warnings:
                                                                      • Montelukast
                                                                        o Should not be used to treat an acute asthma
                                                                          attack: patient should have short-acting
                                                                          beta-agonist
                                                                        o Should not be abruptly substituted for
                                                                          steroids
                                                                        o Chewable tablets contain phenylalanine
                                                                      • Zarfirlukast
                                                                        o Concomitant warfarin therapy
                                                                        o Liver disease
                                                                        o Not for reversal of bronchospasm in acute
                                                                          asthma
                                                                      • Zileuton
                                                                        o Alcohol intake of substantial quantities
                                                                        o History of liver disease
                                                                        o Not for reversal of bronchospasm in acute
                                                                          asthma

II. Therapeutic Uses
     FDA-approved, for example:
     • asthma (Singulair > 12 months of age; Accolate > 5 years of age; Zyflo > 12 years of age)
     • allergic rhinitis - Singulair (perennial > 6 months of age; seasonal > 2 years of age)
     • exercise-induced asthma – Singulair (> 15 years of age)

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

    Asthma
    Montelukast and zafirlukast
    • Documentation of the following is required:
      o appropriate indication; and
      o dose requested is appropriate and does not exceed the following:
          montelukast 10 mg/day
          zafirlukast 40 mg/day (20 mg twice daily).




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Table 40. Leukotriene Modifiers (cont.)
    Zileuton extended-release
    • appropriate indication;
    • an inadequate response, adverse reaction, or contraindication to either montelukast or zafirlukast; and
    • dose requested is appropriate and does not exceed the following.
      o zileuton extended-release 1,200 mg twice daily.

    Allegic Rhinitis
    Montelukast
    • Documentation of the following is required:
      o appropriate indication; and
      o an inadequate response, adverse reaction, or contraindication to at least two of the following oral antihistamines
          cetirizine
          fexofenadine
          loratadine; and
      o an inadequate response, adverse reaction, or contraindication to at least one intranasal antihistamine or intranasal
        corticosteroid; and
      o does requested is appropriate and does not exceed the following
          montelukast 10 mg/day

    All other indications
    All other indications will be evaluated on a case-by-case basis.

    SmartPA: Claims for Singulair (< 60 units/30 days) and Accolate (< 30 units/30 days) will usually process at the
    pharmacy without a prior-authorization request if the member has a history of MassHealth medical claims for asthma,
    MassHealth pharmacy claims for the following drugs for 90 out of the past 120 days: inhaled short-or long-acting beta-2
    agonist or inhaled corticosteroid; or if the member has claims of at least 14 days for an intranasal corticosteroid or
    intranasal antihistamine and at least two of the following antihistamines: loratadine, cetirizine and fexofenadine.†
†
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: 3/2004                                                                Last Revised Date: 2/2009




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                                              MassHealth Evaluation Criteria
                                              Table 41. Topical Antibacterials
Drug Category: Dermatological
Medication Class/Individual Agents: Antibacterial Agents

I. Prior-Authorization Requirements
Drug Name                           PA                  Average          Clinical Notes
                                    Status              Cost Per
                                                        Claim$
bacitracin                                              $3.40            Warnings and Precautions:
chlorhexidine gluconate                                 $2.71-$4.71      • Contact to eyes should be avoided.
clotrimazole                                            $2.16            • Contact with mucosal surfaces should be avoided with
hydrogen peroxide                                       $2.64              mupirocin 2% cream, mupirocin 2% ointment, and
                                                                           retapamulin 1% ointment. Mupirocin 2% nasal
iodine                                                  $4.15-$6.28        ointment is applied into the nostrils.
isopropyl alcohol                                       $1.96            • If severe local irritation occurs, product should be
miconazole                                              $4.66              discontinued.
mupirocin 2% C (Bactroban)                 PA           $88.61           • Prolonged use may result in overgrowth of
mupirocin 2% nasal O (Bactroban)           PA           $88.11             nonsusceptable microorganisms, including fungi.
   mupirocin 2% O (Bactroban #)                         $36.66           • Mupirocin ointment contains polyethylene glycol. This
neomycin                                                $2.99              product should be avoided if large quantities of
                                                                           polyethylene glycol could potentially be absorbed,
polymixin B                                             $2.99              especially in those with moderate-to-severe renal
povidone                                                $4.15-$6.28        impairment (other formulations do not contain
retapamulin 1% O (Altabax)                 PA           $78.78             polyethylene glycol).
triple antibiotic ointment                              $4.17
   (bacitracin/neomycin/polymyxin
   B)
C = cream, O = ointment
# This is 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.
$
  This value represents the average cost per claim of the most commonly prescribed quantities as of 12/2009. Where applicable, cost
  represents that of an “A”-rated generic equivalent (#).

II. Therapeutic Uses
     FDA-approved, for example:
     • Treatment of impetigo or infection due to Staphylococcus aureus or Streptococcus pyogenes-mupirocin cream,
       mupirocin ointment, retapamulin
     • Eradication of nasal colonization by methicillin-resistant Staphylococcus aureus (MRSA)-mupirocin nasal ointment.

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

    Eradication of nasal MRSA colonization
    Bactroban 2% nasal ointment
    • Documentation of the following is required:
      o documentation that intended use is eradication of nasal MRSA colonization.

    Impetigo or infected traumatic lesions
    Bactroban 2% cream and Altabax
    • Documentation of the following is required:
      o documentation of an adverse reaction or inadequate response to all generic mupirocin products.

Original Effective Date: 7/2005                                                                   Last Revised Date: 2/2010
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                                         MassHealth Evaluation Criteria
                                  Table 42. Dermatological Immune Suppressants

Drug Category: Dermatological
Medication Class/Individual Agents: Immune Suppressants

I. Prior-Authorization Requirements
Drug Name                                      PA Status            Clinical Notes
pimecrolimus (Elidel)                          PA                   Topical Immunosuppressants:
tacrolimus (Protopic)                          PA                   • Pimecrolimus and tacrolimus are FDA-
                                                                       approved only for short-term and intermittent
                                                                       long-term use for the treatment of atopic
                                                                       dermatitis.
                                                                    • These agents should be considered second-line
                                                                       therapies and reserved for patients who have
                                                                       failed or have contraindications to conventional
                                                                       therapy.
                                                                    • These agents are not approved for patients less
                                                                       than two years of age and there is limited
                                                                       medical evidence available on the safety of
                                                                       these products in this patient population.

II. Therapeutic Uses
     FDA-approved, for example:
     • Atopic dermatitis (eczema)

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

    Atopic dermatitis (eczema) in members two years of age or older
    • Documentation of the following is required:
      o a diagnosis of atopic dermatitis;
      o member is > two years of age; and
      o treatment failure, adverse reaction/intolerance, or contraindication to at least one high or ultrahigh potency topical
        corticosteroid.

      SmartPA: Claims for Elidel and Protopic for members two years of age and older will usually process at the pharmacy
      without a prior-authorization request if the member has a history of MassHealth medical claims of atopic dermatitis
      and a MassHealth pharmacy claim for high or ultrahigh potency corticosteroid.†
†
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: 8/2005                                                           Last Revised Date: 5/2009




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                                           MassHealth Evaluation Criteria
                                 Table 43. Pulmonary Arterial Hypertension Agents

Drug Category: Cardiovascular Agents
Medication Class/Individual Agents: Peripheral Vasodilators and Pulmonary Hypertension Agents

I. Prior-Authorization Requirements
  Drug Name             PA Status Average Monthly Cost $                 Clinical Notes
  Endothelin Receptor Antagonists                                        2009 America College of Cardiology
  ambrisentan                       $5,355.00                            Foundation/American Heart Association: ACCF/AHA
      (Letairis)                                                         2009 Expert Consensus Document on Pulmonary
  bosentan (Tracleer)               $5,140.80                            Hypertension1
  Phosphodiesterase Type 5 Inhibitors                                    • Goals of treatment include improvement in the patient’s
  sildenafil (Revatio)  PA          $1256.38                                symptoms, quality of life and survival.
  tadalafil (Adcirca)   PA          $941.20                              • Supportive therapy may include warfarin
  Prostanoids                                                               anticoagulation, diuretics and oxygen.
  epoprostenol                      $2,363.88                            • Continuous intravenous epoprostenol improves exercise
      (Flolan#)                                                             capacity, hemodynamics, and survival in pulmonary
  iloprost (Ventavis)               $11,715.00                              hypertension and is the preferred treatment option for
  treprostinil                      $8,473.30- $11,298.00                   the most critically ill patients
      (Remodulin)                                                        • Patients with poor prognostic indexes should be
  treprostinil (Tyvaso)             $11,269.80                              initiated on parenteral therapy, while patients with class
                                                                            II or early III symptoms commonly initiate therapy with
                                                                            endothelin receptor antagonists or PDE-5 inhibitors

                                                                         WHO Classification of Pulmonary Arterial Hypertension
                                                                         • Class I: Patients with no symptoms, and for whom
                                                                           ordinary physical activity pain does not cause fatigue,
                                                                           palpitation, dyspnea, or anginal pain
                                                                         • Class II: Patients who are comfortable at rest but who
                                                                           have symptoms with less-than-ordinary physical
                                                                           activity
                                                                         • Class III: Patients who are comfortable at rest but have
                                                                           symptoms with less-than-ordinary effort
                                                                         • Class IV: Patients who have symptoms at rest.

                                                                         Key symptoms of PAH include fatigue, dizziness and
                                                                         fainting (near syncope).
                                                                         1
                                                                          America College of Cardiology Foundation and American
                                                                         Heart Association: ACCF/AHA 2009 Expert Consensus
                                                                         Document on Pulmonary Hypertension: A Report of the
                                                                         American College of Cardiology Foundation Task Force on
                                                                         Expert Consensus Documents and the American Heart
                                                                         Association Developed in Collaboration With the American
                                                                         College of Chest Physicians; American Thoracic Society, Inc.;
                                                                         and the Pulmonary Hypertension Association. J Am Coll Cardiol.
                                                                         2009 Apr 28;53(17):1573-619.
# This is 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.
$
  This value represents the average monthly cost of the most commonly prescribed quantities as of 12/2009. Where applicable, cost
  represents that of an A-rated generic equivalent (#).

II. Therapeutic Uses
     FDA-approved, for example:
     • Treatment of primary or secondary pulmonary arterial hypertension

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

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Table 43. Pulmonary Arterial Hypertension Agents (cont.)
III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

    Adcirca (tadalafil), Revatio (sildenafil)
    • Documentation of the following is required:
      o an appropriate diagnosis; and
      o member is at least 18 years of age; and
      o prescriber is or has consulted with a cardiologist or pulmonologist; and
      o dose is appropriate.

Original Effective Date: 5/2010




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                                             MassHealth Evaluation Criteria
                                            Table 44. Hepatitis Antiviral Agents

Drug Category: Anti-infectives
Medication Class/Individual Agents: Hepatitis antivirals

I. Prior-Authorization Requirements
Drug Name                                          PA Status                     Clinical Notes
Oral/Injectable                                                                  Alfa-Interferons warnings and precautions:
adefovir (Hepsera)                                 PA > 30 units/month           • Life-threatening or fatal
entecavir solution (Baraclude)                     PA > 600 ml/month                neuropsychiatric, autoimmune, ischemic,
                                                                                    and infectious disorders may be caused
entecavir tablet (Baraclude)                       PA > 30 units/month
                                                                                    or aggravated by alfa interferons.
interferon alfa-2b; IFN-alfa2; rIFN-                                                Monitor patients closely with periodic
   alpha-2; alpha-2 interferon (Intron A)                                           clinical and laboratory evaluations. See
interferon alfa-2b/ribavirin (Rebetron)            PA                               manufacturers’ information for full
interferon alfacon-1 (Infergen)                                                     details.
lamivudine solution (Epivir HBV)                   PA > 600 ml/month
lamivudine tablet (Epivir HBV)                     PA > 30 units/month           Ribavirin warnings and precautions:
peginterfereon alfa-2a (Pegasys)                   PA > 4 doses/month;           • Cardiac disease, pregnancy,
                                                    PA (effective 5/17/10)          hemoglobinopathy, hepatic
peginterfereon alfa-2b (PEG-Intron)                PA > 4 doses/month;              decompensation, autoimmune hepatitis,
                                                    PA (effective 5/17/10)          renal function impairment, pulmonary
ribavirin (Ribapak)                                PA                               function, suicidal ideation. See
                                                                                    manufacturers’ information for full
ribavirin solution (Rebetol)                       PA > 18 years                    details.
ribavirin 200 mg tablet (Copegus #,
   Ribasphere), 200 mg capsule (Rebetol #,
   Ribasphere)
ribavirin 400 mg, 600 mg (Ribasphere)              PA
telbivudine (Tyzeka)                               PA > 30 units/month
# This is 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.

II. Therapeutic Uses
    FDA-approved, for example:
    • Hepatitis B (chronic) – Baraclude, Epivir HBV, Hepsera, Intron A, Tyzeka
    • Hepatitis C (chronic) – Infergen, Intron A, Pegasys, PEG-Intron, ribavirin, Rebetron

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

    Adefovir (> 30 units/month), entecavir solution (> 600 ml/month), entacavir tablets (> 30 units/month),
    lamivudine solution (> 600 ml/month), lamivudine tablets (> 30 units/month), and telbivudine (> 30 units/month)
    • Documentation of the following is required:
      o diagnosis of hepatitis B with evidence of active viral replication and either evidence of persistent transaminase
        elevations or histologically active disease; and
      o medical necessity for additional medication exceeding the quantity limits.

    PEG-Intron and Pegasys
    • Documentation of the following is required:
      o hepatitis C virus RNA levels > 50 international units/ml;
      o hepatitis C virus genotype;

May 3, 2010                                                        135
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Table 44. Hepatitis Antiviral Agents (cont.)

      o requested duration of therapy;
      o member is > 18 years of age; and
      o member has not previously used pegylated interferon alfa products.

    Rebetron
    • Documentation of the following is required:
      o medical necessity, with a well-defined clinical rationale explaining why the member cannot use the commercially
        available separate agents.

    Rebetol solution for members > 18 years of age
    • Documentation of the following is required:
      o medical necessity for a solution formulation.

    Ribapak
    • Documentation of the following is required:
      o compelling rationale why the conventionally packaged forms cannot be used; or
      o demonstration that the requested medication provides a significant or unique therapeutic advantage
        over the conventionally packaged form.

    Ribavirin 400 mg and 600 mg tablets
    • Documentation of the following is required:
      o compelling rationale why the member cannot take a sufficient amount of the 200 mg tablets to achieve the
        desired dose.

Original Effective Date: 4/2004                                                       Last Revised Date: 5/2010




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                                       MassHealth Evaluation Criteria
                                    Table 45. Injectable Antidiabetic Agents
Drug Category: Endocrine/Metabolic
Medication Class/Individual Agents: Injectable antidiabetic agents

I. Prior-Authorization Requirements
Drug Name                                        PA Status                         Clinical Notes
Insulin                                                      Insulin:
insulin aspart, prefilled syringe (Novolog,      PA          • Rapid-acting: aspart, lispro, glulisine
   Novolog 70/30)                                               o onset: 15-30 minutes
insulin aspart, vial (Novolog, Novolog 70/30)                   o duration: 3-5 hours
insulin detemir, prefilled syringe (Levemir)     PA          • Short-acting: regular
insulin detemir, vial (Levemir)                                 o onset: 30-60 minutes
insulin glargine, prefilled syringe (Lantus)     PA             o duration: 5-8 hours
insulin glargine, vial (Lantus)                              • Intermediate-acting: NPH
insulin glulisine, prefilled syringe (Apidra)    PA             o onset: 1-3 hours
insulin glulisine, vial (Apidra)                                o duration: 18-24 hours
insulin lispro, prefilled syringe (Humalog,      PA          • Long-acting: glargine, detemir
   Humalog 50/50, Humalog 75/25)                                o onset: 1-2 hours
insulin lispro, vial (Humalog, Humalog 50/50,                   o duration: 36 hours
   Humalog 75/25)
NPH insulin, prefilled syringe (Humulin N,       PA          Exenatide precautions:
   Novolin N)                                                • Exenatide is not a substitute for insulin.
NPH insulin, vial (Humulin N, Novolin N)                     • Should not be used in Type 1 diabetes or diabetic
NPH/regular insulin, prefilled syringe           PA            ketoacidosis (DKA)
   (Humulin 70/30, Novolin 70/30)                            • Pancreatitis: post-marketing cases reported
NPH/regular insulin, vial (Humulin 50/50,                    • Anti-exenatide antibodies and hypersensitivity reactions
   Humulin 70/30, Novolin 70/30)                             • Concurrent use with exenatide and insulin, D-
regular insulin, prefilled syringe (Novolin R)   PA            phenylalanine derivatives, meglitinides, or alpha-
regular insulin, vial (Humulin R, Novolin R)                   glucosidase inhibitors has not been studied.
Miscellaneous                                                • Exenatide is not recommended for use in patients
exenatide (Byetta)                               PA          • with end-stage renal disease or severe renal impairment.
liraglutide (Victoza)                            PA          • Exenatide is not recommended for use in patients with
pramlintide (Symlin)                             PA            severe gastrointestinal disease.
                                                             • Hypoglycemia

                                                             Pramlintide contraindications:
                                                             • Known hypersensitivity to pramlintide or any of its
                                                                components, including metacresol
                                                             • A confirmed diagnosis of gastroparesis
                                                             • Hypoglycemia unawareness

                                                             Patients who meet any of the following criteria should not
                                                             be considered for pramlintide therapy:
                                                             • Poor compliance with current insulin regimen
                                                             • Poor compliance with prescribed self-blood glucose
                                                                monitoring
                                                             • HbA1c > 9%
                                                             • Recurrent severe hypoglycemia requiring assistance in
                                                                the past six months
                                                             • Pediatric patients
                                                             • Patients requiring medications that stimulate
                                                                gastrointestinal motility




May 3, 2010                                               137
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Table 45. Injectable Antidiabetic Agents (cont.)

II. Therapeutic Uses
     FDA-approved, for example:
     • diabetes mellitus (insulin, Symlin)
     • type 2 diabetes mellitus (Byetta)

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

    Prefilled insulin syringes or cartridges
    • Documentation of the following is required:
      o medical necessity for prefilled insulin syringes or cartridges, for example:
            physical disability
            visual impairment
            cognitive impairment; or
            school age child, adolescent or teenager to facilitate insulin administration during school hours.

    Smart PA: Claims for prefilled insulin syringes and cartridges will usually process at the pharmacy without a prior
    authorization request if the member has a history of MassHealth pharmacy claims for Alzheimer’s disease, Parkinson’s
    disease, muscular dystrophy, rheumatoid arthritis, osteoarthritis, diabetic peripheral neuropathy, blindness and low
    vision, dementias, or mental retardation.†

    Exenatide (Byetta), liraglutide (Victoza)
    • Documentation of the following is required:
      o an FDA-approved indication;
      o member is > 18 years of age; and
      o inadequate glycemic control (HbA1c > 7%) despite a trial of adequate duration of therapy (> 90 days) on metformin
        and least one other oral anti-hyperglycemic agent from a different class; or
      o contraindication to metformin therapy; and
      o inadequate glycemic control (HbA1c > 7%) despite a trial of adequate duration of therapy (> 90 days) on a
        combination of at least two oral anti-hyperglycemic agent from different classes.

    Pramlintide (Symlin)
    • Documentation of the following is required:
      o an FDA-approved indication;
      o member is > 18 years of age;
      o indication is for adjunct treatment in a member with diabetes mellitus who use mealtime insulin therapy;
      o inadequate glycemic control (HbA1c) and postprandial glucose greater than 180 mg/dl despite an adequate
        duration of insulin therapy; and
      o member is not on any medications that stimulate gastrointestinal motility or for the treatment of gastroparesis
        (e.g., metoclopramide).

†
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: 9/2003                                                          Last Revised Date: 12/2008




May 3, 2010                                                   138
  Therapeutic Class and Clinical Criteria Tables

                                          MassHealth Evaluation Criteria
                                         Table 46. Urinary Antispasmodics
Drug Category: Renal and Urinary
Medication Class/Individual Agent: Urinary Antispasmodics
I. Prior-Authorization Requirements
  Drug Name                         PA Status       Average             Clinical Notes
                                                        Monthly
                                                        Cost $
 Oral/Transdermal                                                       • Published literature does not support the use of
 darifenacin 7.5 mg (Enablex)          PA > 30          $122.00           one agent over another.
                                       units/month                      • Once daily dosing with extended-release agents
 darifenacin 15 mg (Enablex)                            $122.00           tend to have less antimuscarinic side effects than
 fesoterodine 4 mg (Toviaz)            PA > 30          $240.83           the immediate-release products.
                                       units/month
 fesoterodine 8 mg (Toviaz)                             $120.41
 flavoxate (Urispas #)                                  $210.41(#)
 oxybutynin (Ditropan #)                                $7.20(#)
 oxybutynin extended-release                            $224.75
    (Ditropan XL)
 oxybutynin gel (Gelnique)             PA               $120.33
 oxybutynin transdermal system         PA               $131.25
    (Oxytrol)
 solifenacin 5 mg (VESIcare)           PA > 30          $127.89
                                       units/month
  solifenacin 10 mg (VESIcare)                              $127.89
  tolterodine (Detrol)                                      $138.83
  tolterodine 2 mg extended-release       PA > 30           $120.37
     (Detrol LA)                          units/month
  tolterodine 4 mg extended-release                         $120.41
     (Detrol LA)
  trospium (Sanctura)                                       $140.89
  trospium extended-release (Sanctura                       $116.11
     XR)
# This is 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.
$
    This value represents the average monthly cost of the most commonly prescribed quantities as of 7/2009. Where applicable,
   cost represents that of an A rated generic equivalent (#).

  II. Therapeutic Uses
       FDA-approved
       • Treat overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency.

  III. Evaluation Criteria for Approval
       • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
       • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

      Oxybutynin transdermal formulations
      • Documentation of the following is required:
        o an intolerable adverse reaction to extended-release oxybutynin; or
        o medical necessity for a transdermal formulation.




  May 3, 2010                                                 139
Therapeutic Class and Clinical Criteria Tables

Table 46. Urinary Antispasmodics (cont.)

    Darifenacin 7.5 mg (> 30 units/month), fesoterodine 4 mg (> 30 units/month), solifenacin 5 mg (> 30 units/month),
    and tolterodine 2 mg extended-release (> 30 units/month)
    • Documentation of the following is required:
      o appropriate diagnosis; and
      o medical necessity for additional medication exceeding the quantity limits.

Original Effective Date: 11/2009                                                  Last Revised Date: 11/2009




May 3, 2010                                              140
  Therapeutic Class and Clinical Criteria Tables

                                                MassHealth Evaluation Criteria
                                               Table 47. Oral Antifungal Agents

Drug Category: Anti-infectives
Medication Class/Individual Agent: Oral Antifungal Agents
II. Prior-Authorization Requirements
 Drug Name         PA          Average    Clinical Notes
                   Status      Cost $ Per
                               Claim
 clotrimazole                  $163.05    • Terbinafine is only FDA-approved for the treatment of onychomycosis of the
    troche                                    toenail and fingernail due to dermatophytes.
    (Mycelex)                             • Certain azole antifungals have medication specific adverse events:
 Fluconazole                   $1.76-         o Fluconazole is associated with alopecia.
     (Diflucan #)              $101.99        o Itraconazole is associated with aldosterone-like effects and should be avoided
                               (#)               in patients with a history of heart failure.
 flucytosine                   $4,923.03      o Voriconazole is associated with abnormal vision and rash.
 (Ancobon)
 griseofluvin                  $130.38    • Voriconazole is an effective agent for aspergillus, scedosporium, and fusarium
     (Fulvicin #,                             infections.
     Grifulvin #,                         • Posaconazole is the only azole antifungal with activity against zygomycosis
     Gris-Peg #)                              infections.
 itraconazole                  $219.21    • Azole antifungals are potent inhibitors of various CYP450 enzymes:
     (Sporanox #)              (#)
 ketoconazole,                 $10.00 (#)                 Cytochrome P-450 Metabolism of Oral Antifungals
     oral                                    Agent               2C19 2C9           3A4       1A2     2A6      2E1       2D6
     (Nizoral #)                             fluconazole         X(S)     X(S)      X(M)
 nystatin, oral                $22.03        itraconazole                           X(S)
    Mycostatin                               voriconazole        X(W) X(W) X(M)
    #, Nilstat #)                            posaconazole                           X(S)
 posaconazole      PA          $3,905.18     ketoconazole                           X(S)      X(M) X(M) X(M)
    (Noxafil)                                clotrimazole                           X(M)
 terbinafine       PA          $221.13       terbinafine                            X(S)                                 X(S)
    granule
    (Lamisil)                             • Hepatic function abnormalities are associated with the azole class including
 terbinafine                   $10.75 (#)     terbinafine and as such, careful monitoring of liver function tests are
     tablet                                   recommended in all patients receiving these agents. Specific monitoring
     (Lamisil #)                              recommendations include:
 voriconazole      PA          $700.69        o voriconazole: at initiation and during course of treatment
     Suspension                               o itraconazole: for all patients being treated for longer than one month
     (VFend)                                  o terbinafine: prior to initiation and should be repeated if used for > six weeks
 voriconazole      PA          $1,137.78      o posaconazole: at the start of and during the course of therapy
     tablet
     (VFend)
# This is 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.
$
  This value represents the average cost per claim of the most commonly prescribed quantities as of 9/2009. Where applicable, cost
  represents that of an A-rated generic equivalent (#).

  II. Therapeutic Uses
       FDA-approved, for example:
       • prophylaxis against candida and aspergillus infections – Noxafil
       • oropharyngeal candidiasis – Noxafil
       • invasive Aspergillus infectons – VFend
       • candidemia – VFend
       • esophageal candidiasis – VFend
       • disseminated candidiasis – VFend
       • fungal infections caused by Scedosporium and Fusarium – VFend
  May 3, 2010                                                        141
Therapeutic Class and Clinical Criteria Tables

Table 47. Oral Antifungal Agents (cont.)
    Non FDA-approved, for example:
    • oropharyngeal – candidiasis – VFend
    • zygomycosis fungal infections – Noxafil
    • esophageal candidiasis – Noxafil
    • aspergillus endophthalmitis and keratitis – VFend

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

III. Evaluation Criteria for Approval
     • All prior-authorization requests must include clinical diagnosis, drug name, dose, and frequency.
     • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

    Prevention of invasive aspergillus and candida fungal infections (Noxafil)
    • Documentation of the following is required:
      o member is > 13 years of age; and
      o diagnosis of hematopoietic stem cell transplantation (HSCT) and graft-versus-host disease (GVHD); or
      o acute myelogenous leukemia (AML) and neutropenia; or
      o myelodysplastic syndromes (MDS) and neutropenia.

    Treatment of oropharyngeal candidiasis (Noxafil)
    • Documentation of the following is required:
      o member is > 13 years of age; and
      o inadequate response, adverse reaction, or contraindication to all less costly antifungal agents:
          nystatin or clotrimazole;
          fluconazole; and
          itraconazole.

    Treatment of zygomycosis infection (Noxafil)
    • Documentation of the following is required:
      o member is > 13 years of age.

    Treatment of esophageal candisiasis (Noxafil)
    • Documentation of the following is required:
      o member is > 13 years of age; and
      o inadequate response, adverse reaction, or contraindication to all of the following:
          fluconazole; and
          voriconazole.

    Treatment of aspergillus, scedosporium and fusarium infections (VFend)
    • Documentation of the following is required:
      o member is > 12 years of age.

    Treatment of candidemia and disseminated candidiasis infections (VFend)
    • Documentation of the following is required:
      o member is > 12 years of age; and
      o inadequate response, adverse reaction, or contraindication to fluconazole.

    Treatment of esophageal candidiasis (VFend)
    • Documentation of the following is required:
      o member is > 12 years of age; and
      o inadequate response, adverse reaction, or contraindication to all of the following:
          fluconazole; and
          itraconazole.
May 3, 2010                                                   142
Therapeutic Class and Clinical Criteria Tables

Table 47. Oral Antifungal Agents (cont.)

    Treatment of oropharyngeal candidiasis (VFend)
    • Documentation of the following is required:
      o member is > 12 years of age; and
      o inadequate response, adverse reaction, or contraindication to all of the following:
          nystatin or clotrimazole;
          fluconazole; and
          posaconazole.

    Treatment of aspergillus endophthalmitis and keratitis (VFend)
    • Documentation of the following is required:
      o member is > 12 years of age.

Original Effective Date: 2/2010




May 3, 2010                                                  143
                                   Commonwealth of Massachusetts
                                   MassHealth Drug Utilization Review Program
                                   P.O. Box 2586
                                   Worcester, MA 01613-2586
                                   Fax: 1-877-208-7428 Phone: 1-800-745-7318

 Anticonvulsant Prior Authorization Request

                                   MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth
                                   approves the request, payment is still subject to all general conditions of MassHealth, including current
                                   member eligibility, other insurance, and program restrictions. MassHealth will notify the provider and member
                                   of its decision. Keep a copy of this form for your records. If faxing this form, please use black ink.

                                   PA is required for Banzel, Lamictal XR, Lyrica, Keppra XR, Sabril and Vimpat (tablet only). PA is required for
                                   Gabitril and for topiramate for members older than 18 years. Additional information about anticonvulsants,
                                   including PA requirements, can be found within the MassHealth Drug List at www.mass.gov/druglist.




 Member information
  Last name                                  First name                            MI   MassHealth member ID no.           Date of birth   Gender (Circle one.)
                                                                                                                                                 f     m
  Member’s place of residence                  home                  nursing facility




 Medication information: Section I
  Anticonvulsant request                                  Dose, frequency, and duration of requested drug               Drug NDC (if known) or service code
  (Check one or all that apply.)
                                                          Indication for anticonvulsant requested (Check one or all that apply.)
      Banzel (rufinamide)                                    Seizure disorder
      Gabitril (tiagabine)                                   Type:
      Keppra XR (levetiracetam extended-release)             Postherpetic neuralgia
      Lamictal XR (lamotrigine extended-release)             Infantile spasms
      Lyrica (pregabalin)
                                                             Other (describe):
      Sabril (vigabatrin)
      topiramate
      Vimpat (lacosamide) tablet                          Please list all other medications currently prescribed for the member for this indication.




  Is member currently hospitalized for this condition?i             Yes          No
  Has member ever been hospitalized for this condition?             Yes. Dates of most recent hospitalization: ___________________________________
                                                                    No
  Is member under the care of a neurologist?                        Yes          No
  Is member under the care of a psychiatrist?                       Yes          No

        Name of neurologist and/or psychiatrist: __________________________________________                  Telephone no.: _______________________

        Date of last visit with neurologist and/or psychiatrist: ______________________________




PA-18 (Rev. 02/10)                                                                                                                                         over 
Medication information: Section II
 Please complete this section if indication is
                                                        A. Drug name
 NOT for a seizure disorder. (This section does
 not need to be completed if indication is for a
                                                        Dates of use                                         Dose and frequency
 seizure disorder.)
 Has member tried other medications for this
 condition?                                               Briefly describe details of adverse reaction, inadequate response, intolerance, or other.
    Yes. Complete Box A.
    No. Explain why not.



                                                    Note: You may be asked to provide supporting documentation (e.g., copies of medical records,
                                                          office notes, and/or completed FDA MedWatch form).




                                                        B. Drug name

                                                        Dates and length of use                              Maximum daily dose
 Has member previously tried requested
 anticonvulsant?
    Yes. Complete Box B.                                  Briefly describe how member responded to the requested anticonvulsant.
    No. Explain why not.




                                                    Note: You may be asked to provide supporting documentation (e.g., copies of medical records,
                                                          office notes, and/or completed FDA MedWatch form).




Pharmacy information
 Name                                                          Pharmacy provider no.         Telephone no.                  Fax no.
                                                                                  Optional   (      )                       (         )                Optional
 Address                                                                                     City                           State         Zip
                                                                                                                                                       Optional



Prescriber information
 Last name                                 First name                               MI       MassHealth provider no.        DEA no.

 Address                                                                                     City                           State         Zip

 E-mail address                                                                              Telephone no.                  Fax no.
                                                                                  Optional   (      )                       (         )


Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification, omission, or
concealment of material fact may subject me to civil or criminal liability.



 Prescriber’s signature (Stamp not accepted.)                                                                                                   Date
                                 Commonwealth of Massachusetts
                                 MassHealth Drug Utilization Review Program
                                 P.O. Box 2586
                                 Worcester, MA 01613-2586
                                 Fax: 1-877-208-7428 Phone: 1-800-745-7318

 Antidepressant Prior Authorization Request
                                 MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth approves
                                 the request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other
                                 insurance, and program restrictions. MassHealth will notify the provider and member of its decision. Keep a copy of
                                 this form for your records. If faxing this form, please use black ink.

                                 PA is required for Aplenzin, bupropion XL, Cymbalta, Effexor XR, EMSAM, Lexapro, Luvox CR, mirtazapine orally
                                 disintegrating tablet, paroxetine CR, Pexeva, Pristiq, Prozac Weekly, Sarafem, Symbyax, Wellbutrin XL, and brand-
                                 name multiple-source antidepressants that have an FDA “A”-rated generic equivalent. Additional information about
                                 antidepressants can be found within the MassHealth Drug List at www.mass.gov/druglist.



 Member information
   Last name                                 First name                                  MI   MassHealth member ID no.      Date of birth Gender (Circle one.)
                                                                                                                                                   f   m
   Member’s place of residence                  home                  nursing facility




 Medication information
   Antidepressant request                                 Dose, frequency, and duration of requested drug                Drug NDC (if known)
        Aplenzin
        bupropion XL                                      Indication for antidepressant requested (Check all that apply.)
        Cymbalta
        Effexor XR                                          Depression                                     Panic disorder
        EMSAM                                               Obsessive-compulsive disorder                  Premenstrual dysphoric disorder
        Lexapro                                             Other (describe):
        Luvox CR
        mirtazapine orally disintegrating tablet
        paroxetine CR
        Pristiq
        Prozac Weekly                                     Please list all other psychotropic medications currently prescribed for the member.
        Symbyax
        Other: _____________________________
        Brand name * ______________________

     *Please attach supporting documentation
     (e.g., copies of medical records, office notes,
     and/or completed FDA Medwatch form
     regarding adverse reaction or inadequate
     response to the generic product.)
   Has member been hospitalized for this condition?

     Yes. Dates of most recent hospitalization: ______________________________________________                              No

   Is member under the care of a psychiatrist?            Yes         No
   Name of psychiatrist: __________________________________________                 Telephone no. _______________________
   Date of last visit or consult with psychiatrist______________________________

PA-13 (Rev. 08/09)                                                                                                                                     over 
Medication information (cont.)
 For Lexapro, documentation of a trial of citalopram and one other SSRI is required.
 For Cymbalta documentation of a trial of at least one SSRI and one other antidepressant (which may include another SSRI) is required. For Effexor
 XR, documentation of a trial of venlafaxine ER tablets and at least one other antidepressant is required.
 Please complete Boxes A and B below to document past antidepressant trials.
 For all other antidepressant requests (e.g., orally disintegrating tablets, Aplenzin, bupropion XL, EMSAM, Luvox CR, paroxetine CR, Prozac Weekly,
 Wellbutrin XL, etc), please describe the medical necessity for the medication requested (attach letter with details if more space is needed)*:




 A. SSRI name
 Dates of use                                                                  Dose and frequency


 Did member experience any of the following?
    Adverse reaction           Inadequate response              Intolerance              Other

    Briefly describe details of adverse reaction, inadequate response, intolerance, or other:




 B. SSRI or other antidepressant name
 Dates of use                                                                  Dose and frequency


 Did member experience any of the following?
    Adverse reaction           Inadequate response              Intolerance              Other

    Briefly describe details of adverse reaction, inadequate response, intolerance, or other:




* Prescriber may be asked to provide supporting documentation (e.g., copies of medical records and/or office notes).


Pharmacy information
 Name                                                         Pharmacy provider no.          Telephone no.                 Fax no.
                                                                                             (      )                      (         )
                                                                                  Optional                                                            Optional
 Address                                                                                     City                          State         Zip
                                                                                                                                                      Optional



Prescriber information
 Last name                                First name                                MI       MassHealth provider no.       DEA no.


 Address                                                                                     City                          State         Zip

 E-mail address                                                                              Telephone no.                 Fax no.
                                                                                Optional     (      )                      (         )

Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification, omission, or
concealment of material fact may subject me to civil or criminal liability.



 Prescriber’s signature (Stamp not accepted.)                                                                                                  Date
                               Commonwealth of Massachusetts
                               MassHealth Drug Utilization Review Program
                               P.O. Box 2586
                               Worcester, MA 01613-2586
                               Fax: 1-877-208-7428 Phone: 1-800-745-7318

Antipsychotic Prior Authorization Request
                               MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth
                               approves the request, payment is still subject to all general conditions of MassHealth, including current member
                               eligibility, other insurance, and program restrictions. MassHealth will notify the requesting provider and member
                               of its decision. Keep a copy of this form for your records. If faxing this form, please use black ink.

                               PA is required for Abilify Discmelt, Fanapt, Fazaclo, Invega, risperidone orally dissolving tablets, Saphris, and
                               Zyprexa Zydis.

                               PA is required for duplicative antipsychotic pharmacotherapy, or an overlap of 60 days or more in prescriptions
                               (for any dosage form), of two or more of the following atypical antipsychotics: Abilify, Fanapt, Geodon, Invega,
                               risperidone, Saphris, Seroquel, Seroquel XR, and Zyprexa.

                               PA is required for quantity requests greater than 30 units/month for Abilify tablet, Seroquel XR 150 and 200
                               mg, and Zyprexa; greater than 60 units/month for Geodon capsule, risperidone tablet, and Seroquel XR 50
                               mg, 300 mg and 400 mg; greater than 90 units/month for Seroquel; greater than 750 ml/month for Abilify
                               solution; greater than 1 syringe per month of Invega Sustenna after initial 2 syringe loading dose, greater than
                               2 syringes/month of Zyprexa Relprevv 210 mg and 300 mg, greater than 1 syringe/month of Zyprexa Relprevv
                               405 mg, greater than 2 syringes/month for Risperdal Consta; and greater than 480 ml/month for risperidone
                               solution. Additional information about antipsychotics, including PA requirements, can be found within the
                               MassHealth Drug List at www.mass.gov/druglist.

Member information
 Last name                                First name                                 MI     MassHealth member ID no.        Date of birth Gender (Circle one.)
                                                                                                                                                      f   m
 Member’s place of residence                 home                 nursing facility


Medication information
 Indication for antipsychotic requested (Check all that apply.)

       Schizophrenia                  Bipolar disorder                   Irritability associated with autistic disorder in children and adolescents
       Other:

 Medication requested                                                 Dose


 Section I: Monotherapy
 Please choose the medication and check the following reasons for medical necessity:

         Fanapt                         Trial of a generic atypical AND Trial of two other antipsychotics
         Invega                         Member new to MassHealth and previously stabilized on requested medication.
         Saphris                        Other, please explain:


 For the following rapid dissolving dosage forms please choose the medication and check reason for medical necessity:

         Abilify Discmelt               Member needs rapidly dissolving tablet for 30 day stabilization and will then be switched to tablet/
         Fazaclo                        capsule. All other medications at this time are either liquid or injectable.
         risperidone rapidly            Other, please explain:
         dissolving tablet
         Zyprexa Zydis



PA-19 (Rev. 05/10)                                                                                                                                        OVER
Medication information (cont.)
Section II: Duplicate Therapy                               Dose and frequency of first requested antipsychotic
   Please check medications below and fill in
   information to the right for a PA request due            Dose and frequency of second requested antipsychotic
   to duplicative antipsychotic pharmacotherapy.
        Abilify (aripiprazole)                                 Member recently discharged from inpatient setting on requested medications.
        Fanapt (iloperidone)                                   Please allow combination for another 90 days to allow for taper of one medication.
        Geodon (ziprasidone)
                                                               Member has experienced sub-optimal response on maximum dose of monotherapy
        Invega (paliperidone)                                  and a second agent is required for full response.
        risperidone
        Saphris (asenapine)                                    Member is in the process of transitioning from one antipsychotic to the other.
        Seroquel (quetiapine)                                   Other, please explain:
        Seroquel XR (quetiapine extended-release)
        Zyprexa (olanzapine)

Section III: Quantity Limits                                   Member is not a candidate for dose consolidation (e.g. Zyprexa 5mg BID and can be
   Please check medications below and fill in               consolidated to Zyprexa 10mg QD, which does not require PA).
   information to the right for a PA request due
   to doses exceeding established quantity limits.          Please describe medical necessity for dosing this medication in a manner which exceeds
        Abilify (aripiprazole)                              quantity limits.
        Abilify Oral solution (aripiprazole)
        Geodon (ziprasidone)
        Invega Sustenna
        Risperdal Consta
        risperidone
        risperidone oral solution
        Seroquel (quetiapine)
        Seroquel XR (quetiapine extended-release)
        Zyprexa (olanzapine)
        Zyprexa Relprevv (olanzapine pamoate)

Pharmacy information
 Name                                                         Pharmacy provider no.           Telephone no.                Fax no.

                                                                                   Optional
                                                                                              (      )                     (         )              Optional
Address                                                                                       City                         State         Zip
                                                                                                                                                    Optional

Prescriber information
Last name                                      First name                            MI       MassHealth provider no.      DEA no.

Address                                                                                       City                         State         Zip

E-mail address                                                                                Telephone no.                Fax no.
                                                                                              (      )                     (         )
                                                                                  Optional

Prescribing Provider’s Attestation, Signature, and Date
I certify that I am the prescribing provider identified in the Prescriber information section of this form. Any attached statement on my letterhead has
been reviewed and signed by me. I certify that the medical necessity information (per 130 CMR 450.204) on this form is true, accurate, and complete, to
the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of
any material fact contained herein.

Prescribing provider’s signature (signature and date stamps, or the signature of anyone other than the prescribing provider, are not acceptable):



Date:
                              Commonwealth of Massachusetts
                              MassHealth Drug Utilization Review Program
                              P.O. Box 2586
                              Worcester, MA 01613-2586
                              Fax: 1-877-208-7428 Phone: 1-800-745-7318

Erythropoietin Prior Authorization Request
                              MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth
                              approves the request, payment is still subject to all general conditions of MassHealth, including current
                              member eligibility, other insurance, and program restrictions. MassHealth will notify the provider and member
                              of its decision. Keep a copy of this form for your records. If faxing this form, please use black ink.
                              Prior authorization is required for all erythropoietin products. Information about which drugs require PA can
                              be found within the MassHealth Drug List at www.mass.gov/masshealth.

Member information
Last name                                First name                               MI      MassHealth member ID no.        Date of birth   Sex (Circle one.)
                                                                                                                                              f    m
Member’s place of residence                home                nursing facility          Height                           Weight



Medication information                    (When appropriate, please consider multidose vial use.)
 Drug name requested                          Dose, frequency, and duration                                      Drug NDC (if known) or service code

 Indication for erythropoietin (Check one or all that apply.):

        Chronic renal failure
         Is the member on hemodialysis?            Yes    No
        (Please Note: If member is on hemodialysis, please contact                     HIV
         dialysis clinic for proper billing procedure.)                                Please provide medication regimen.
         Please provide most recent serum creatinine and/or
         creatinine clearance.




                                                                                       Anemic surgical patient
                                                                                       Type of procedure:
                                                                                       Date of procedure:
        Renal transplant
        Is the member on hemodialysis?        Yes        No                            Please provide medical necessity for the use of
                                                                                       erythropoietin:
        Cancer chemotherapy
        Please provide type of cancer and dates chemotherapy will be
        given.                                                                         Other
                                                                                       Please provide medical necessity for the use of erythropoietin




        Hepatitis C
        Please provide antiviral medication regimen and any dose
        adjustments attempted.




PA-8 (Rev. 07/05)                                                                                                                                   over u
Laboratory information
Current Hematocrit/Hemoglobin:                                            date:
Erythropoietin level (if available):
Have other causes of anemia been ruled out (hemolysis, iron, vitamin B12, and folate deficiency)? Yes         No
If no, please provide further justificatiion for erythropoietin.




Continuation of therapy
Please complete sections above about indication for erythropoietin and labratory information.

Please provide documentation of member’s response to therapy (e.g., quality of life, activities of daily living).




Has member been transfused in past six months?            Yes          No
If yes, please provide explanation.




Target hematocrit:



If target hematocrit has been met, please provide plan for decreasing dose.




Pharmacy information
Name                                                            Pharmacy provider no.       Telephone no.                      Fax no.
                                                                                 Optional   (      )                           (         )            Optional
Address                                                                                     City                               State         Zip
                                                                                                                                                      Optional



Prescriber information
Last name                                 First name                                MI      MassHealth provider no.            DEA no.
                                                                                                                    Optional
Address                                                                                     City                               State         Zip

E-mail address                                                                              Telephone no.                      Fax no.
                                                                                 Optional   (      )                           (         )


Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification,
omission, or concealment of material fact may subject me to civil or criminal liability.


Prescriber’s signature (Stamp not accepted.)                                                                                                   Date
                                Commonwealth of Massachusetts
                                MassHealth Drug Utilization Review Program
                                P.O. Box 2586
                                Worcester, MA 01613-2586
                                Fax: 1-877-208-7428 Phone: 1-800-745-7318

Forteo Prior Authorization Request
                                 MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth approves
                                 the request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other
                                 insurance, and program restrictions. MassHealth will notify the provider and member of its decision. Keep a copy of
                                 this form for your records. If faxing this form, please use black ink.

                                 PA is required for Forteo.

                                 Additional information about Forteo can be found within the MassHealth Drug List at www.mass.gov/masshealth.


Member information
 Last name                                  First name                                  MI   MassHealth member ID no.      Date of birth   Sex (Circle one.)
                                                                                                                                               f m
 Member’s place of residence                   home                  nursing facility


Medication information
 Section I
 Forteo 20 mcg SQ once a day
 Forteo ______________________________________________________________ (Please specify dosing regimen and rationale for this regimen.)
 Indication for Forteo (Check one or all that apply.)
        Post menopausal osteoporosis (PMO)              Primary/Hypogonadal osteoporosis           Other: ________________________________________

 Has member had a radiographically confirmed fracture?
         Yes. Please provide site of fracture and date of occurence (if known): ________________________________________________
         No.
 Date/results of baseline BMD measurements: Please provide baseline T-scores of total hip and lumbar vertebrae (L1-L4).




 Date/results of any subsequent BMD measurements: Please provide T-scores of total hip and lumbar vertebrae (L1-L4).




 Is member under the care of a rheumatologist or endocrinologist?                 Yes         No

     Name of rheumatologist or endocrinologist: _______________________________________________________________

     Date of last visit with rheumatologist or endocrinologist: ____________________________________________

 Please list all supplements and medications currently prescribed for this member.




 Please list all non-modifiable risk factors for fracture in this member.




PA-21 (Rev. 07/05)                                                                                                                                  over u
Medication information (cont.)
 Section II
 Has member tried alendronate (Fosamax) to treat this condition?
              Yes. Complete box A.           No. Explain why not.


 A. Dates of use                                                                Dose and frequency

 Did member experience any of the following?             Adverse reaction            Inadequate response                Other

    Briefly describe details of adverse reaction, inadequate response, or other:


 Has member tried risedronate (Actonel) to treat this condition?
             Yes. Complete box B.           No. Explain why not.


 B. Dates of use                                                               Dose and frequency

 Did member experience any of the following?             Adverse reaction            Inadequate response            Other

   Briefly describe details of adverse reaction, inadequate response, or other:


 Has member tried ibandronate (Boniva) to treat this condition?
             Yes. Complete box C.           No. Explain why not.


 C. Dates of use                                                               Dose and frequency

 Did member experience any of the following?             Adverse reaction            Inadequate response            Other

   Briefly describe details of adverse reaction, inadequate response, or other:




Pharmacy information
 Name                                                         Pharmacy provider no.           Telephone no.                     Fax no.
                                                                                  Optional    (      )                          (         )                Optional
 Address                                                                                      City                              State         Zip
                                                                                                                                                           Optional



Prescriber information
 Last name                                First name                                 MI       MassHealth provider no.           DEA no.

 Address                                                                                      City                              State         Zip

 E-mail address                                                                               Telephone no.                     Fax no.
                                                                                   Optional   (      )                          (         )

Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification, omission, or
concealment of material fact may subject me to civil or criminal liability.



 Prescriber’s signature (Stamp not accepted.)                                                                                                       Date
                                Commonwealth of Massachusetts
                                MassHealth Drug Utilization Review Program
                                P.O. Box 2586
                                Worcester, MA 01613-2586
                                Fax: 1-877-208-7428 Phone: 1-800-745-7318

Growth Hormone Adult Prior Authorization Request
                                MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth
                                approves the request, payment is still subject to all general conditions of MassHealth, including current
                                member eligibility, other insurance, and program restrictions. MassHealth will notify the provider and member
                                of its decision. Keep a copy of this form for your records. If faxing this form, please use black ink.
                                Prior authorization is required for all growth hormone products. Information about which drugs require PA
                                can be found within the MassHealth Drug List at www.mass.gov/masshealth.

Member information
Last name                                   First name                                   MI    MassHealth member ID no.      Date of birth         Sex (Circle one.)
                                                                                                                                                       f        m
Member’s place of residence                   home                  nursing facility


Medication information
Drug name requested                                Dose, frequency, and duration                                  Drug NDC (if known) or service code

 Indication for GH: For HIV wasting, fill out Section A. For growth hormone deficiency (GHD) syndrome in adults, fill out Section B.
 Section A
 HIV wasting - Initial prior authorization
 Current height                                    Current weight                                                 Date

 Premorbid weight                                  Date                                Diagnosis

 CD4 count                                  Date                                  Has member intentionally lost weight?
                                                                                                                                             Yes                No

Describe attempted nutritional supplementation




 Has member attempted therapy with dronabinol (Marinol) or megestrol acetate (Megace)? If so, provide dates and duration. If not, please explain why.




 Describe current antiretroviral therapy.




Any known tumors?                                                                Is this a female patient who is pregnant?
                                      Yes             No                                                                               Yes                 No

HIV wasting - Reauthorization
Current height                                     Current weight                                                 Date


 Has member maintained or gained weight with GH treatment?



PA-15 (Rev. 04/04)                                                                                                                                              over u
Medication information (cont.)
 Section B
 Growth hormone deficiency (GHD) syndrome in adults
Current height                                    Current weight                                               Date

Is the growth hormone deficiency adult onset?                 Yes          No

 If so, provide etiology of GH deficiency.



 Please provide dates and results of GH stimulation tests performed. If stimulation test was not performed, please explain why not.




 IGF-I level        e

 Provide detailed signs and symptoms of growth hormone deficiency syndrome and provide documentation of diagnostic procedures, lab tests,
 radiological tests, and clinical findings.




Any known tumors?                                                            Is this a female patient who is pregnant?
                                       Yes          No                                                                           Yes          No

 Provide date of last appointment with endocrinologist




Pharmacy information
Name                                                         Pharmacy provider no.       Telephone no.                    Fax no.
                                                                                         (       )                       (          )
Address                                                                                  City                            State          Zip




Prescriber information
Last name                                    First name                           MI     MassHealth provider no.         DEA no.

Address                                                                                  City                            State          Zip

E-mail address                                                                           Telephone no.                   Fax no.
                                                                                         (       )                       (          )


Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification,
omission, or concealment of material fact may subject me to civil or criminal liability.


Prescriber’s signature (Stamp not accepted.)                                                                                              Date
                               Commonwealth of Massachusetts
                               MassHealth Drug Utilization Review Program
                               P.O. Box 2586
                               Worcester, MA 01613-2586
                               Fax: 1-877-208-7428 Phone: 1-800-745-7318

Growth Hormone Pediatric Prior Authorization Request
                               The Division reviews requests for prior authorization (PA) on the basis of medical necessity only. If the
                               Division approves the request, payment is still subject to all general conditions of MassHealth, including
                               current member eligibility, other insurance, and program restrictions. The Division will notify the provider and
                               member of its decision. Keep a copy of this form for your records. If faxing this form, please use black ink.
                               Prior authorization is required for all growth hormone products. Information about which drugs require PA,
                               and additional information about the PA requirements can be found within the MassHealth Drug List at
                               www.mass.gov/druglist.

Member information
Last name                                    First name                              MI       MassHealth member ID no.     Date of birth   Sex (Circle one.)
                                                                                                                                                f   m
Member’s place of residence                    home               nursing facility


Medication information
Drug name requested                              Dose, frequency, and duration                                   Drug NDC (if known) or service code



 GH Pediatric Indications
 Indication for growth hormone requested (check one):

    Growth hormone deficiency                                                        Prader Willi syndrome (Provide documentation of genetic testing)

    Growth reduction due to chronic renal failure                                    Small for gestational age with failed catch-up by age 2

    Noonan syndrome (Provide documentation of genetic testing.)                      Turner syndrome (Provide documentation of genetic testing)

                                                                                     Other:




 Fill in applicable information below for indication and attach supporting documentation (e.g., copies of medical records, office notes, growth charts,
 diagnostic studies, laboratory tests).

 Current height                                  Current weight                                                  Date

 Growth rate in past year                                                        Date of GH stimulation tests
                                                                          cm

 Provide type of GH stimulation tests performed and results




 IGF-I level                          Date                              Bone age exam results                                 Date

Any known tumors?                      Yes            No                        Female patient pregnant?                       Yes             No

 Provide date of last appointment with endocrinologist

PA-16 (Rev. 02/10)                                                                                                                                     OVER
Pharmacy information
Name                                                   Pharmacy provider no.       Telephone no.              Fax no.
                                                                        Optional   (      )                   (         )            Optional
Address                                                                            City                       State         Zip
                                                                                                                                     Optional



Prescriber information
Last name                               First name                         MI      MassHealth provider no.    DEA no.

Address                                                                            City                       State         Zip

E-mail address                                                                     Telephone no.              Fax no.
                                                                        Optional   (      )                   (         )


Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification,
omission, or concealment of material fact may subject me to civil or criminal liability.


Prescriber’s signature (Stamp not accepted.)                                                                                  Date
                              Commonwealth of Massachusetts
                              MassHealth Drug Utilization Review Program
                              P.O. Box 2586
                              Worcester, MA 01613-2586
                              Fax: 1-877-208-7428 Phone: 1-800-745-7318
Hypnotic Prior Authorization Request
                              MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth approves
                              the request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other
                              insurance, and program restrictions. MassHealth will notify the requesting provider and member of its decision. Keep a
                              copy of this form for your records. If faxing this form, please use black ink.

                              PA is required for Ambien CR, Doral, Edluar, Lunesta, Rozerem, and any brand-name multiple-source hypnotic that has
                              an FDA “A”-rated generic equivalent as identified by the Approved Drug Products with Therapeutic Equivalence
                              Evaluations (also called the “Orange Book”).

                              PA is also required for quantity requests greater than 30 units per month for estazolam, flurazepam, temazepam 15
                              and 30 mg, triazolam, zaleplon and zolpidem 10 mg. PA is required for quantity requests greater than 45 units per
                              month for zolpidem 5 mg. Additional information about hypnotic use, including PA requirements, can be found within
                              the MassHealth Drug List at www.mass.gov/druglist.

Member information
Last name                                  First name                                MI    MassHealth member ID no. Date of birth Gender (Circle one.)
                                                                                                                                            f    m
Member’s place of residence                  home                 nursing facility


Medication information
Hypnotic request                     Quantity       Hypnotic request                      Quantity   Hypnotic request                 Quantity
  Ambien # (zolpidem)                                   estazolam                                       Rozerem (ramelteon)
  Ambien CR (zolpidem)                                  Halcion # (triazolam)                           Sonata # (zaleplon)
  Dalmane # (flurazepam)                                Lunesta (eszopiclone)                           temazepam
  Doral (quazepam)                                      Restoril (temazepam)                            Other
  Edluar (zolpidem)
Dose, frequency, and duration of requested drug                                            Drug NDC (if known)



Section I
A. Indication for hypnotic
             Insomnia            Other

B. Is insomnia secondary to a vital concurrent medication or diagnosis?
             Yes. Please briefly describe and attach documentation.



             No

C. Has member been counseled on good sleep hygiene practices?
           Yes. Please briefly describe.



             No. Please explain why not.

D. Is request for quantities greater than 30 units (> 45 units of zolpidem 5 mg) per month of a hypnotic?
             Yes. Please briefly describe and attach documentation, including detailed treatment plan and
             therapeutic endpoints.



             No

PA-11 (Rev. 05/10)                                                                                                                               OVER
Medication information
 Section II
 What other medications has the member tried for this diagnosis (sleep disorder), for example, benzodiazepines, trazodone, tricyclic
 antidepressants, or mirtazapine?
 Please attach supporting documentation (e.g., copies of medical records, office notes,
 and/or completed FDA MedWatch form) for your response to this question.

        Drug name                                   Dates of use                                        Dose and frequency




 Did the member experience any of the following?

              Adverse reaction                         Inadequate response                      Other

 Please briefly describe details of adverse reaction, inadequate response, or other.




Pharmacy information
 Name                                                         Pharmacy provider no.         Telephone no.                    Fax no.
                                                                                Optional    (      )                      (            )         Optional
 Address                                                                                    City                          State            Zip
                                                                                                                                                 Optional



Prescriber information
 Last name                                First name                               MI       MassHealth provider no.       DEA no.

 Address                                                                                    City                          State            Zip

 E-mail address                                                                             Telephone no.                 Fax no.
                                                                                 Optional   (      )                      (            )


Prescribing Provider’s Attestation, Signature, and Date
I certify that I am the prescribing provider identified in the Prescriber information section of this form. Any attached statement on my letterhead
has been reviewed and signed by me. I certify that the medical necessity information (per 130 CMR 450.204) on this form is true, accurate, and
complete, to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or
concealment of any material fact contained herein.

Prescribing provider’s signature (signature and date stamps, or the signature of anyone other than the prescribing provider, are not acceptable):



Date:
                               Commonwealth of Massachusetts
                               MassHealth Drug Utilization Review Program
                               P.O. Box 2586
                               Worcester, MA 01613-2586
                               Fax: 1-877-208-7428 Phone: 1-800-745-7318

Immune Globulin Intravenous (IGIV) Prior Authorization Request
                               MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth
                               approves the request, payment is still subject to all general conditions of MassHealth, including current
                               member eligibility, other insurance, and program restrictions. MassHealth will notify the provider and member
                               of its decision. Keep a copy of this form for your records. If faxing this form, please use black ink.
                               IGIV requires prior authorization. Additional information about which drugs require PA can be found within the
                               MassHealth Drug List at www.mass.gov/druglist.


Member information
Last name                                  First name                                  MI     MassHealth member ID no.    Date of birth   Sex (Circle one.)
                                                                                                                                              f    m
Member’s place of residence                     home             nursing facility            Height                       Weight



Medication information
Drug name requested                              Dose, frequency, and duration                                   Drug NDC (if known) or service code

 Provide rate of administration. Note: Rate of administration may require adjustment for members with or at risk for renal dysfunction.


 Indication for IGIV (Check one or all that apply.):
    Immunodeficiency syndrome                                                    Pediatric HIV infection
     Provide date and result of most recent serum immunoglobulin levels.         Provide date and result of most recent CD4 count.



                                                                                    Other (describe):
     Idiopathic thrombocytopenic purpura (ITP)
    Provide date and result of most recent platelet count.
    Is member actively bleeding?        Yes. (Describe) No




    B-cell chronic lymphocytic leukemia (CLL)


    Kawasaki disease
    Provide date of onset.


    Bone marrow transplantation
    Provide type and date of transplant.




PA-17 (Rev. 04/05)                                                                                                                                  over u
Pharmacy information
Name                                                   Pharmacy provider no.       Telephone no.              Fax no.
                                                                        Optional   (      )                   (         )            Optional
Address                                                                            City                       State         Zip
                                                                                                                                     Optional



Prescriber information
Last name                               First name                         MI      MassHealth provider no.    DEA no.

Address                                                                            City                       State         Zip

E-mail address                                                                     Telephone no.              Fax no.
                                                                        Optional   (      )                   (         )


Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification,
omission, or concealment of material fact may subject me to civil or criminal liability.


Prescriber’s signature (Stamp not accepted.)                                                                                  Date
                              Commonwealth of Massachusetts
                              MassHealth Drug Utilization Review Program
                              P.O. Box 2586
                              Worcester, MA 01613-2586
                              Fax: 1-877-208-7428 Phone: 1-800-745-7318
Narcotic Prior Authorization Request
                              MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth approves
                              the request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other
                              insurance, and program restrictions. MassHealth will notify the provider and member of its decision. Keep a copy of
                              this form for your records. If faxing this form, please use black ink.

                              Information about the MassHealth Drug List can be found at www.mass.gov/druglist. Please refer to the
                              Therapeutic Class and Clinical Criteria Tables and Pain Initiative for specific information about prior-authorization
                              requirements for narcotics.

Member information
Last name                                First name                                MI       MassHealth member ID no.       Date of birth   Sex (Circle one.)
                                                                                                                                              f       m
Member’s place of residence                home                 nursing facility


Medication information
 PA is required for:                                                                    PA is also required for the duplicate long acting
 -fentanyl buccal film (Onsolis)                                                        Narcotic therapy defined as: prescriptions for > 2
 -fentanyl transdermal (Duragesic)*                                                     long-acting narcotics for >3 months. Other Narcotic
                                                                                        analgesics may also require PA
 -fentanyl transmucosal (Actiq, Fentora)
 -oxycodone controlled-release (CR) (OxyContin)*                                        Drug name (requested)
 -oxymorphone immediate release (IR)/extended release (ER) (Opana)
 -meperidine (Demerol)                                                                  Dose and frequency of requested drug
 -morphine ER (Avinza)
 -morphine SR (Kadian)                                                               Expected duration of therapy
 -morphine/naloxone (Embeda)                                                           < 6 months                > 6 months
 -tapentadol (Nucynta)
 *Members will be exempt from PA if a pharmacy received a paid claim for                Indication
 these drugs for the member within the past 90 days and dose limits and                    Cancer pain (specify type and stage):
 quanity limits are not exceeded.

 Additional information is required for Narcotic requests that                             AIDS:
 exceed dose or quantity limits. Please provide medical records
 and complete section III                                                                  Other (specify):
 Dose limits:
 fentanyl transdermal (Duragesic) >200 mcg/hr
 meperidine (Demerol) >750 mg/day                                                       For all requests, please complete applicable Sections
 oxycodone CR (OxyContin) > 240 mg/day                                                  (I, II, AND III)
 oxymorphone IR and ER (Opana) >120 mg/day                                              -If request is for narcotic powder, a dose or quantity that
 codeine >360 mg/day                                                                    exceeds dose/quantity limits, or any long-acting narcotic
 hydromorphone >60 mg/day                                                               therapy, please complete Sections I and III.
 morphine IR >360 mg/day
 oxycodone IR >240 mg/day                                                               Opioid Therapy Algorithm
 levorphanol >32 mg/day
                                                                                        Step 1: non-narcotic analgesics   Step 3: long-acting morphine
 methadone >120 mg/day
                                                                                        -NSAIDS/acetaminophen.            Step 4: methadone (if clinically
 morphine CR (MS Contin, Oramorph SR, generics), ER
                                                                                        - If neuropathic pain consider    appropriate)
 (Avinza), sustained-release (SR) (Kadian) >360 mg/day
                                                                                        tricyclic antidepressants         Step 5: oxycodone CR
                                                                                        (TCAs), anticonvulsants           Step 6: fentanyl
 Quantity limits:
                                                                                        Step 2: short-acting opioids      Step 7: oxymorphone
 fentanyl transdermal (Duragesic) >30 patches/month
                                                                                        (acute pain)
 oxycodone CR (OxyContin) >90 tabs/month
 oxymorphone IR and ER (Opana) >90 tabs/month                                           CR = controlled release; ER = extended release;
                                                                                        IR = immediate release; SR = sustained release

PA-12 (Rev. 02/10)                                                                                                                                    over 
Medication information (cont.)
 Section I
   Has the member been treated with other pain medications for this condition? Please include details
   below and attach medical records, if applicable:




 Section II
   Please complete for fentanyl transdermal, oxycodone CR, and oxymorphone ER requests.
   □ Has the member tried a long acting morphine product?
    □ Yes (Complete boxes below.) □ No. (Provide explanation.)




Dates of use                                                               Dose and frequency


Did member experience any of the following?                Adverse reaction               Inadequate response           Other
Details of adverse reaction, inadequate response, or other:




 Section III
   Please complete the following for all requests for narcotic powders,        Does the member have:
   narcotics exceeding dose and quantity limits, or long-acting narcotic       A history of substance abuse or dependence?                     Yes     No
   analgesic therapy:                                                          A history of alcohol abuse or dependence?                       Yes     No
      Is the member under the care of a pain specialist?    Yes      No
      Name of specialist:                                                      A treatment agreement (e.g., lock-in pharmacy and prescriber,
      Phone no.:(   )                                                          early refill policy, consequences of nonadherence to treatment)?

   Date of last visit or consult with pain specialist:
   Please attach copy of pain consult note if available.                          Yes (Attach copies.)          No (Provide explanation.)

   Please document complete pain-management regimen, including
   other pain medications, adjunctive therapy, and/or controlled
   substances (including medication names and doses).




Pharmacy information
 Name                                                         Pharmacy provider no.        Telephone no.                 Fax no.
                                                                               Optional   (      )                       (         )                 Optional
 Address                                                                                  City                           State           Zip
                                                                                                                                                     Optional

Prescriber information
 Last name                                First name                              MI      MassHealth provider no.        DEA no.

 Address                                                                                  City                           State           Zip

 E-mail address                                                                           Telephone no.                  Fax no.
                                                                               Optional   (      )                       (         )
Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification, omission, or
concealment of material fact may subject me to civil or criminal liability.

Prescriber’s signature (Stamp not accepted.)                                                                                           Date
                                 Commonwealth of Massachusetts
                                 MassHealth Drug Utilization Review Program
                                 P.O. Box 2586
                                 Worcester, MA 01613-2586
                                 Fax: 1-877-208-7428 Phone: 1-800-745-7318
Nonsteroidal Anti-Inflammatory Drugs (NSAID)
Prior Authorization Request
                                  MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth
                                  approves the request, payment is still subject to all general conditions of MassHealth, including current
                                  member eligibility, other insurance, and program restrictions. MassHealth will notify the provider and member
                                  of its decision. Keep a copy of this form for your records. If faxing this form, please use black ink.

                                  PA is required for Arthrotec, Celebrex, Mobic, Nalfon, Naprelan, Solaraze, Voltaren Gel, Zipsor, and generic
                                  extended-release NSAIDs. In addition, PA is required for Ponstel (single-source brand-name NSAID) and any
                                  brand-name multiple-source NSAID that has an FDA “A”-rated generic equivalent as identified by the
                                  Approved Drug Products with Therapeutic Equivalence Evaluations (also called the “Orange Book”).
                                  Additional information about NSAIDs use, including PA requirements, can be found within the MassHealth
                                  Drug List at www.mass.gov/druglist.

Member information
Last name                                    First name                                 MI      MassHealth member ID #           Date of birth   Sex (Circle one.)
                                                                                                                                                     f    m
Member’s place of residence                     home                 nursing facility


Medication information Please complete section 1 below or section 2 on back, depending on the drug requested.
1.   Drug requested                                       Dose, frequency, and duration of requested drug                  Drug NDC (if known)
       Arthrotec (misoprostol/diclofenac)
       Celebrex (celecoxib)
       Mobic (meloxicam)
       Nalfon                                             Is member under 60 years of age?              Yes           No
       Solaraze
       Voltaren Gel
       Zipsor
       Other

     Indications (Check one.)
        Osteoarthritis               Primary dysmenorrhea              Familial adenomatous polyposis (celecoxib only: FDA-approved)
        Rheumatoid arthritis         Acute pain                        Other, specify

     Is member at risk for a clinically significant gastrointestinal event, as defined by one of the following?
       Yes (Check one.)                                                                                                           Dates
                                Previous history:         Major GI bleed          Perforation           Obstruction
                                                                                                                                  Dates
                                Previous history of a peptic ulcer documented by endoscopy or radiograph

       Concomitant therapy with any of the following (Check one.)

                                Aspirin     Oral corticosteroid: dose, frequency,                       Warfarin: dose, frequency,
                                            and duration                                                and duration

       No. Has member tried two generic NSAID products?
                                Yes. Complete boxes 3A and 3B on back            No. Explain why not.
                                (Generic NSAID product courses).




PA-7 (Rev. 02/10)                                                                                                                                          OVER
Medication information continued
2.   Brand-name multiple-source NSAID or Ponstel request Dose, frequency, and duration of requested drug            Drug NDC (if known)

     Diagnosis pertinent to requested medication

     Has member tried two generic products?
       Yes. Complete boxes 3A and 3B below           No. Explain why not.
        (Generic NSAID product courses).




3. Generic NSAID product courses
     A. Drug name                                                              B. Drug name

     Dates of generic use                       Dose and frequency             Dates of generic use                          Dose and frequency

     Did member experience any of the following?                               Did member experience any of the following?
        Adverse reaction      Inadequate response           Other                Adverse reaction       Inadequate response           Other
        Details of adverse reaction, inadequate response, or other               Details of adverse reaction, inadequate response, or other




Pharmacy information
 Name                                                         Pharmacy provider no.       Telephone                      Fax
                                                                               Optional   (      )                       (        )                  Optional
Address                                                                                   City                           State          Zip
                                                                                                                                                     Optional



Prescriber information
Last name                                 First name                              MI      MassHealth provider no.        DEA #

Address                                                                                   City                           State          Zip

E-mail address                                                                            Telephone                      Fax
                                                                               Optional   (      )                       (        )

Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification,
omission, or concealment of material fact may subject me to civil or criminal liability.


 Prescriber’s signature (Stamp not accepted.)                                                                                                 Date


DUR program use only
Reviewer’s decision            Approved            Pended           Denied

Comments/reasons for pended or denied decision
                             Commonwealth of Massachusetts
                             MassHealth Drug Utilization Review Program
                             P.O. Box 2586
                             Worcester, MA 01613-2586
                             Fax: 1-877-208-7428 Phone: 1-800-745-7318
Oral Antibiotic Prior Authorization Request
                             MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If
                             MassHealth approves the request, payment is still subject to all general conditions of MassHealth,
                             including current member eligibility, other insurance, and program restrictions. MassHealth will
                             notify the requesting provider and member of its decision. Keep a copy of this form for your
                             records. If faxing this form, please use black ink.


                             Additional information about oral antibiotics, including PA requirements, can be found within the
                             MassHealth Drug List at www.mass.gov/druglist.


Member information
Last name                               First name                   MI       MassHealth member ID no.   Date of birth Gender (Circle one.)
                                                                                                                             f     m
Member’s place of residence               home             nursing facility


Medication information
 Drug Requested:
      Adoxa (all strengths)                                      Doryx                                   Oracea 40 mg capsule
      Augmentin XR                                               Flagyl ER 750 mg tablet                 Solodyn (all strengths)
      cefaclor extended-release                                  Ketek                                   Vancocin tablet
      cefadroxil 1 gram tablet                                   Keflex 750 mg capsule                   Xifaxan
      ciprofloxacin extended-release 500 mg or 1,000 mg          metronidazole 375 mg capsule            Zyvox 600 mg tablet
      clarithromycin extended-release 500 mg                     Monodox 75 mg capsule                   Zyvox 100 mg/5 ml suspension
      clindamycin 300 mg capsule                                 Moxatag


   Dose, frequency, and duration of requested drug:

   Indication:

   Has member tried other antibiotics to treat this condition?      Yes          No
   If yes, please provide the drug name, dose, frequency, and result of therapy.




   If no, please provide explanation.




   Extended-release antibiotics requests: Please provide the medical necessity for requiring the extended-
   release dosage form over the immediate release agents.




PA-24 (Rev. 05/10)                                                                                                                 over 
 clindamycin 300 mg, cefadroxil 1 gm, Keflex 750 mg, or metronidazole 375 mg requests:
    Please provide documentation of the medical necessity for requiring the requested strength over other less costly available
    strengths.




 Ketek requests:
    Please provide documentation of the medical necessity for requiring Ketex over other clinically appropriate agents.




 Monodox, Adoxa, Oracea, Doryx, or Solodyn requests:
    Please document the medical necessity for the branded formulation over available generic strengths/formulations.




 Zyvox tablet or suspension requests:
    Was the culture positive for vancomycin-resistant Enterococcus?                                                         Yes      □   No

    Was the culture positive for MRSA?                                                                                      Yes      □   No

    Is the infection resistant or unresponsive to sulfamethoxazole/TMP?                                                     Yes      □   No

    Is the infection resistant or unresponsive to clindamycin?                                                              Yes      □   No

    Is the infection resistant or unresponsive to doxycycline or minocycline?                                               Yes      □   No

    Please provide any additional clinical information.

Pharmacy information
 Name                                                         Pharmacy provider no.         Telephone no.                  Fax no.
                                                                                 Optional   (      )                       (         )              Optional
Address                                                                                     City                           State          Zip
                                                                                                                                                    Optional

Prescriber information
Last name                                 First name                                MI      MassHealth provider no.        DEA no.

Address                                                                                     City                           State          Zip

E-mail address                                                                              Telephone no.                  Fax no.
                                                                                 Optional   (      )                       (         )

Prescribing Provider’s Attestation, Signature, and Date
I certify that I am the prescribing provider identified in the Prescriber information section of this form. Any attached statement on my letterhead has
been reviewed and signed by me. I certify that the medical necessity information (per 130 CMR 450.204) on this form is true, accurate, and complete, to
the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of
any material fact contained herein.

Prescribing provider’s signature (signature and date stamps, or the signature of anyone other than the prescribing provider, are not acceptable):



Date:
                            Commonwealth of Massachusetts
                            MassHealth Drug Utilization Review Program
                            P.O. Box 2586
                            Worcester, MA 01613-2586
                            Fax: 1-877-208-7428 Phone: 1-800-745-7318
Pegylated Interferon for Hepatitis C Prior Authorization Request
                             MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If
                             MassHealth approves the request, payment is still subject to all general conditions of MassHealth,
                             including current member eligibility, other insurance, and program restrictions. MassHealth will
                             notify the requesting provider and member of its decision. Keep a copy of this form for your
                             records. If faxing this form, please use black ink.

                             PA is required for all pegylated interferon products including peginterfereon alfa-2b (PEG-Intron)
                             and peginterfereon–alfa-2a (Pegasys). Additional clinical information is also required for quantities
                             greater than 4 doses/month of the pegylated interferon products.

                             Additional information about hepatitis antiviral agents, including PA requirements, can be found
                             within the MassHealth Drug List at www.mass.gov/druglist.


Member information
Last name                              First name                    MI       MassHealth member ID no.   Date of birth Gender (Circle one.)
                                                                                                                             f     m
Member’s place of residence               home             nursing facility


Medication information
 Section I Requests for medication:
      peginterfereon alfa-2a (Pegasys)
      peginterfereon alfa-2b (PEG-Intron)

  Dose/frequency:

  Duration of therapy:

  HCV Genotype:     1    2     3     4
  Age ≥ 18 years old?    Yes       No
  Has member previously had a trial of pegylated interferon?       Yes          No

  Does the member have a comorbid medical condition that may impact this request for pegylated interferon?           Yes      No

  If so, please indicate other diagnosis (diagnoses):




  Section II
  Please complete Section II for a PA request exceeding > 4            Please describe medical necessity for dosing this medication in
  doses/month.                                                         a manner which exceeds the quantity limits.

      peginterfereon alfa-2a (Pegasys)
      peginterfereon alfa-2b (PEG-Intron)




PA-25 (05/10)                                                                                                                 over 
Pharmacy information
 Name                                                  Pharmacy provider no.        Telephone no.              Fax no.
                                                                         Optional   (      )                   (         )          Optional
Address                                                                             City                       State         Zip
                                                                                                                                    Optional




Prescriber information
Last name                             First name                           MI       MassHealth provider no.   DEA no.

Address                                                                             City                      State          Zip

E-mail address                                                                      Telephone no.             Fax no.
                                                                         Optional   (      )                   (         )


Prescribing Provider’s Attestation, Signature, and Date
I certify that I am the prescribing provider identified in the Prescriber information section of this form. Any attached statement on my
letterhead has been reviewed and signed by me. I certify that the medical necessity information (per 130 CMR 450.204) on this form is
true, accurate, and complete, to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution
for any falsification, omission, or concealment of any material fact contained herein.
Prescribing provider’s signature (signature and date stamps, or the signature of anyone other than the prescribing provider, are not
acceptable):

Date:
                               Commonwealth of Massachusetts
                               MassHealth Drug Utilization Review Program
                               P.O. Box 2586
                               Worcester, MA 01613-2586
                               Fax: 1-877-208-7428 Phone: 1-800-745-7318
Proton Pump Inhibitor Prior Authorization Request
                               MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth
                               approves the request, payment is still subject to all general conditions of MassHealth, including current
                               member eligibility, other insurance, and program restrictions. MassHealth will notify the requesting provider
                               and member of its decision. Keep a copy of this form for your records. If faxing this form, please use black
                               ink.
                               PA is required for Aciphex, Dexilant, Nexium, pantoprazole, and brand-name multiple-source proton pump
                               inhibitors that have an FDA “A”-rated generic equivalent. PA is required for lansoprazole capsules for
                               members two years of age and older. Generic omeprazole does not require PA. Additional information about
                               PPI use, including PA requirements, can be found within the MassHealth Drug List at www.mass.gov/druglist.

Member information
Last name                                 First name                                     MI    MassHealth member ID #          Date of birth    Gender (Circle one.)
                                                                                                                                                       f    m
Member’s place of residence                    home                 nursing facility


Indication for proton pump inhibitor (Check all that apply.)
  GERD                                                                                 Duodenal ulcer                 Gastric ulcer
     Moderate-severe erosive esophagitis                                                 Helicobacter pylori:
     Uncomplicated nonerosive esophagitis                                                         Positive                           Negative
         Has an H2 antagonist previously been tried?                                     Drug-induced:
            Yes. State drug name, dose, frequency, and duration.                                  Treatment: List causative agent(s):




            No. Explain why not.                                                                  Prevention: List risk factor(s):


     Barrett’s esophagus or esophageal strictures                                        Other cause (specify):
     GERD in child with one of the following conditions:
            Severe chronic respiratory disease (specify):
                                                                                       Non-ulcer or functional dyspepsia
                                                                                       Has an H2 antagonist previously been tried?
            Neurologic disability (specify):                                                      Yes. State drug name, dose, frequency, and duration.

            Other (specify):

                                                                                                  No. Explain why not.
  Condition associated with extraesophageal symptoms
  secondary to gastric reflux
     Noncardiac chest pain      Asthma                                                 Pathological hypersecretory syndromes
     Idiopathic hoarseness                     Chronic laryngitis                        Zollinger-Ellison syndrome
     Other (explain):                                                                    MEN Type I
                                                                                         Other:

  Other (explain):


PA-4 (Rev. 05/10)                                                                                                                                              over 
Diagnostic studies performed (include dates of studies)
  Describe any diagnostic studies performed, including dates of studies.




Medication information
Important Note: For maximum efficacy, a proton pump inhibitor (PPI) must be taken in a fasting state, just before or with breakfast. If a
second dose is necessary, the second dose should be taken just before the evening meal. In general, it is not necessary to prescribe other
antisecretory agents (H2 antagonists, prostaglandins) for patients on PPIs. If an antisecretory agent is prescribed with a PPI, the PPI should
not be taken within six hours of the antisecretory agent.

 PPI requested                                       Dose, frequency, and duration of PPI                          Drug or service code


 Has member tried generic omeprazole? (Note: generic omeprazole does not require prior authorization.)

    Yes. Provide the following information about the use of generic omeprazole.                                       No. Explain why not.

 Dates of use                                        Dose and frequency


 If member received generic omeprazole, why was it discontinued? (Check one or all that
 apply.)
    Adverse reaction       Inadequate response          Intolerance       Other:




Pharmacy information
 Name                                                       Pharmacy provider no.        Telephone no.                    Fax no.
                                                                              Optional   (      )                        (          )         Optional
Address                                                                                  City                            State          Zip
                                                                                                                                              Optional



Prescriber information
Last name                               First name                                 MI    MassHealth provider no.         DEA no.

Address                                                                                  City                            State          Zip

E-mail address                                                                           Telephone no.                   Fax no.
                                                                              Optional   (      )                        (          )


Prescribing Provider’s Attestation, Signature, and Date
I certify that I am the prescribing provider identified in the Prescriber information section of this form. Any attached statement on my
letterhead has been reviewed and signed by me. I certify that the medical necessity information (per 130 CMR 450.204) on this form is
true, accurate, and complete, to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution
for any falsification, omission, or concealment of any material fact contained herein.

Prescribing provider’s signature (signature and date stamps, or the signature of anyone other than the prescribing provider, are not
acceptable):

Date:
                               Commonwealth of Massachusetts
                               MassHealth Drug Utilization Review Program
                               P.O. Box 2586
                               Worcester, MA 01613-2586
                               Fax: 1-877-208-7428 Phone: 1-800-745-7318
Lipid Lowering Agent Prior Authorization Request
                                MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth approves
                                the request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other
                                insurance, and program restrictions. MassHealth will notify the requesting provider and member of its decision. Keep a
                                copy of this form for your records. If faxing this form, please use black ink.

                                PA is required for quantities greater than 30 units per month for all statins. In addition to the quantity limits, PA is
                                required for Altoprev, Crestor, Lescol, Lescol XL, Lipitor, Vytorin and brand-name multiple-source statins that have an
                                FDA “A”-rated generic equivalent. Additional information about lipid lowering agents, including PA requirements, use can
                                be found within the MassHealth Drug List at www.mass.gov/druglist.

Member information
Last name                                   First name                                 MI   MassHealth member ID no.       Date of birth    Gender (Circle one.)
                                                                                                                                                      f   m
Member’s place of residence                   home                  nursing facility


Medication information
 Statins                                             Fibric Acids                           Dose, frequency, and duration of requested drug, and
                                                                                            quantity/month
    Altoprev                                             Antara
    Crestor                                              Fenoglide                          Drug or NDC (if known)
    Lescol                                               Fibricor
                                                                                            Indication for medication requested
    Lescol XL                                            Lipofen
                                                                                            (Check one or all that apply.)
    Lipitor                                              Lofibra                               Hypertriglyceridemia
    lovastatin                                           Tricor                                Primary hypercholesterolemia
    pravastatin                                          Triglide                              Mixed dyslipidemia
                                                                                               Secondary prevention of cardiovascular event
    simvastatin                                          Trilipix
                                                                                               Other. Specify pertinent medical history, diagnostic
    Vytorin                                                                                    studies, and/or laboratory results.
                                                     Refer to Section III
    Other:
                                                     Cholesterol Absorption
    Brand name:*
                                                     Inhibitors
                                                                                            Please provide the most current laboratory values:
                                                         Zetia                              Date:
 *Please attach supporting documentation
 (e.g., copies of medical records, office notes,     Refer to Section IV                    Total cholesterol:       mg/dl     HDL:        mg/dl
 and/or completed FDA Medwatch form
 regarding adverse reaction or inadequate            Miscellaneous Agents                   LDL/LDL-C:           mg/dl        Triglycerides:          mg/dl
 response to the generic product)                                                           Please summarize treatment goals including target cholesterol
                                                         Lovaza
                                                                                            levels:
                                                         Welchol
 Refer to Section I and/or II                        Refer to Section V

 Section I
 Please complete for requests for quantities greater than 30 units per month.
 Please provide a rationale for requested dose, quantity, and frequency, including a detailed treatment plan. (Specify pertinent medical history,
 diagnostic studies, and/or lab results.)



 Is member a candidate for dose consolidation? (e.g., member is on simvastatin 10 mg BID, and dose can be consolidated to simvastatin 20 mg QD,
 which does not require PA).          Yes     No
 Please provide rationale for a regimen of greater than one unit per day.


PA-9 (Rev. 05/10)                                                                                                                                         over 
Medication information (cont.)
  Section II
  Please complete if request is for Altoprev, Crestor,                          No. Explain why not.
  Lescol, Lescol XL, Lipitor, Vytorin, or other.
  A. Has member tried simvastatin?
        Yes. Complete Section VI.
 Section III
 Please complete if request is for brand name fenofibrate (Antara,              No. Explain why not.
 Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, Triglide, Trilipix).
  A. Has the member tried generic fenofibrate?
        Yes. Complete Section VI.
 Section IV
 Please complete if request is for Zetia.                                       No. Explain why not.
 A. Has the member tried simvastatin or another statin?
        Yes. Complete Section VI.

 Section V
 Please complete if request is for Lovaza.                                      No. Explain why not.
 A. Has the member tried fenofibrate, gemfibrozil, and niacin?
    Yes. Complete Section VI.
  Please complete if request is for Welchol.                                    No. Explain why not.

  B. Has the member tried a statin and cholestyramine or colestipol?
     Yes. Complete Section VI.

 Section VI
 Previous drug trial(s)                                                                                                 Dates of Use
 Drug name(s), dose, and frequency


  Did the member experience any of the following?

    □ Adverse reaction              □ Inadequate response □            Other

  Briefly describe details of adverse reaction, inadequate response, or other



Pharmacy information
 Name                                                         Pharmacy provider no.           Telephone no.                    Fax no.
                                                                                   Optional   (      )                         (         )          Optional
Address                                                                                       City                            State          Zip
                                                                                                                                                    Optional

Prescriber information
Last name                                  First name                                MI       MassHealth provider no.         DEA no.

Address                                                                                       City                            State          Zip

E-mail address                                                                                Telephone no.                   Fax no.
                                                                                   Optional   (      )                         (         )
Prescribing Provider’s Attestation, Signature, and Date
I certify that I am the prescribing provider identified in the Prescriber information section of this form. Any attached statement on my letterhead has
been reviewed and signed by me. I certify that the medical necessity information (per 130 CMR 450.204) on this form is true, accurate, and complete, to
the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of
any material fact contained herein.

Prescribing provider’s signature (signature and date stamps, or the signature of anyone other than the prescribing provider, are not acceptable):



Date:
                                 Commonwealth of Massachusetts
                                 MassHealth Drug Utilization Review Program
                                 P.O. Box 2586
                                 Worcester, MA 01613-2586
                                 Fax: 1-877-208-7428 Phone: 1-800-745-7318

 Strattera and Cerebral Stimulant Prior Authorization Request
                                 MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth approves
                                 the request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other
                                 insurance, and program restrictions. MassHealth will notify the provider and member of its decision. Keep a copy of this
                                 form for your records. If faxing this form, please use black ink.

                                 PA is required for Strattera (atomoxetine). In addition, PA is required for greater than 60 units per month for long-acting
                                 cerebral stimulants, greater than 90 units per month for short-/intermediate-acting cerebral stimulants, and concurrent
                                 therapy for short-/intermediate - and long-acting cerebral stimulants greater than 90 units per month (all agents
                                 combined). PA is also required for any brand-name multiple-source product that has an FDA “A”-rated generic equivalent
                                 as identified by the Approved Drug Products with Therapeutic Equivalence Evaluations (also called the “Orange Book”).
                                 Additional information about Strattera and cerebral stimulant use can be found within the MassHealth Drug List at
                                 www.mass.gov/druglist.

 Member information
  Last name                                  First name                                  MI MassHealth member ID no.    Date of birth Gender (Circle one.)
                                                                                                                                            f      m
  Member’s place of residence                  home                 nursing facility


 Medication information
  Stratera Request
      Strattera (atomoxetine)       Dose, frequency, and duration                              Drug NDC (if known)
  Cerebral Stimulant Request (Check one or all that apply.)                                    Dose, frequency, and duration
   Long Acting                                     Intermediate Acting/Short Acting
      Adderall XR (amphetamine salts)                  Adderall # (amphetamine salts)          Drug NDC (if known)
      Concerta (methylphenidate)                       Focalin (dexmethylphenidate)
      Focalin XR (dexmethylphenidate)                  Dexedrine # (dextroamphetamine)         Quantity requested per month
      Metadate CD (methylphenidate)                    Dextrostat # (dextroamphetamine)
      Ritalin LA (methylphenidate)                     Liquadd (dextroamphetamine)             Has dose consolidation been attempted? □      Yes       No
                                                       Metadate ER # (methylphenidate)         Please explain why not.
   Indication (Check one or all that apply.)
       Attention Deficit Hyperactivity                 Methylin (methylphenidate)
      Disorder (ADHD)                                  Ritalin # (methylphenidate)
       Narcolepsy                                      Ritalin SR # (methylphenidate)
       Other (Explain)

  Is member under the care of a psychiatrist or behavioral specialist?             Yes         No

   Name of psychiatrist or behavioral specialist ________________________________________________________________________________

   Telephone no.: __________________________                                                          Date of last visit: _________________________

  Please list all medications currently prescribed for this member for this condition.




  Please describe your new treatment plan for managing this member’s condition, including discontinuation of any medications as a result of the
  addition of medication requested.




PA-20 (Rev. 05/09)                                                                                                                                     over
Medication information (cont.)
 Please complete the following sections for Strattera requests. Has member tried other medications in the methylphenidate class
 to treat this condition?
     Yes. Complete Box A.                       No. Explain why not.
 A. Drug name                                           Dates of use                                        Dose and frequency

 Did member experience any of the following?             Adverse reaction        Inadequate response           Intolerance           Other
    Briefly describe details of adverse reaction, inadequate response, intolerance, or other.



 Has member tried other medications in the amphetamine/dextroamphetamine class to treat this condition?
    Yes. Complete Box B.                        No. Explain why not.


 B. Drug name                                           Dates of use                                        Dose and frequency

 Did member experience any of the following?             Adverse reaction        Inadequate response           Intolerance           Other
    Briefly describe details of adverse reaction, inadequate response, intolerance, or other.



 Has member tried other non-stimulant medications to treat this condition?
    Yes. Complete Box C.                        No. Explain why not.


 C. Drug name                                           Dates of use                                        Dose and frequency

 Did member experience any of the following?             Adverse reaction        Inadequate response           Intolerance           Other
    Briefly describe details of adverse reaction, inadequate response, intolerance, or other.



 Note: You may be asked to provide supporting documentation (e.g., copies of medical records, office notes, and/or completed FDA MedWatch form).



Pharmacy information
 Name                                                         Pharmacy provider no.         Telephone no.                    Fax no.
                                                                                 Optional   (      )                         (         )                  Optional
 Address                                                                                    City                             State           Zip
                                                                                                                                                          Optional



Prescriber information
 Last name                                First name                                MI      MassHealth provider no.          DEA no.

 Address                                                                                    City                             State           Zip

 E-mail address                                                                             Telephone no.                    Fax no.
                                                                                 Optional   (      )                         (         )


Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification, omission, or
concealment of material fact may subject me to civil or criminal liability.



 Prescriber’s signature (Stamp not accepted.)                                                                                                      Date
                                Commonwealth of Massachusetts
                                MassHealth Drug Utilization Review Program
                                P.O. Box 2586
                                Worcester, MA 01613-2586
                                Fax: 1-877-208-7428 Phone: 1-800-745-7318

Triptan Prior Authorization Request
                                MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth approves
                                the request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other
                                insurance, and program restrictions. MassHealth will notify the provider and member of its decision. Keep a copy of this
                                form for your records. If faxing this form, please use black ink.

                                PA is required for Amerge, Axert, Frova, Imitrex injection, Imitrex nasal spray, Maxalt, Maxalt-MLT, Relpax, Zomig, Zomig
                                nasal spray, Zomig ZMT, and Treximet. PA is not required for sumatriptan tablets for quantities less than or equal
                                to 9 units per month. Additional information about triptans, includinding PA requirements, can be found within the
                                MassHealth Drug List at www.mass.gov/druglist.


Member information
Last name                                  First name                                  MI    MassHealth member ID no.         Date of birth   Sex (Circle one.)
                                                                                                                                                   f   m
Member’s place of residence                  home                  nursing facility


Medication information
Triptan request                 Quantity request        Dose, frequency, and duration of requested drug
   Amerge tablet
   Axert tablet                                         Indication for triptan requested
   Frova tablet                                             Acute treatment of migraine
                                                           Frequency of migraine attacks (number/month)
   Maxalt tablet
                                                           Is member currently on migraine prophylaxis?
   Maxalt-MLT tablet
                                                              Yes. Specify agent(s), dose, and frequency.
   Relpax tablet
                                                              No. Explain why not.
   sumatriptan tablet
   sumatriptan injection
   sumatriptan nasal spray                                Other. Specify pertinent medical history, diagnostic studies, and/or laboratory tests.
   Treximet
   Zomig tablet
   Zomig-ZMT tablet
   Zomig nasal spray                                    Please attach supporting documentation (e.g., copies of medical records and/or laboratory tests).
   Other:

Has the member tried sumatriptan?
  No. Explain why not
   Yes. Dates of use
Did member experience any of the following?
   Adverse reaction                Inadequate response                         Other
   Briefly describe details of adverse reaction, inadequate response, or other.




Is the member under the care of a neurologist?
    Yes
   No
Name of neurologist
Telephone number
Date of last visit or consult

PA-10 (Rev. 02/10)                                                                                                                                      OVER
Pharmacy information
Name                                                   Pharmacy provider no.        Telephone no.             Fax no.
                                                                                    (      )                  (          )
                                                                         Optional                                                  Optional
Address                                                                             City                      State          Zip

                                                                                                                                   Optional



Prescriber information
Last name                               First name                         MI       MassHealth provider no.   DEA no.


Address                                                                             City                      State          Zip


E-mail address                                                                      Telephone no.             Fax no.
                                                                         Optional   (      )                  (          )


Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification,
omission, or concealment of material fact may subject me to civil or criminal liability.


 Prescriber’s signature (Stamp not accepted.)                                                                     Date
                              Commonwealth of Massachusetts
                              MassHealth Drug Utilization Review Program
                              P.O. Box 2586
                              Worcester, MA 01613-2586
                              Fax: 1-877-208-7428 Phone: 1-800-745-7318

Brand-Name Drug Prior Authorization Request
                              MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth
                              approves the request, payment is still subject to all general conditions of MassHealth, including current
                              member eligibility, other insurance, and program restrictions. MassHealth will notify the provider and member
                              of its decision. Keep a copy of this form for your records. If faxing this form, please use black ink.

                              Prescribers must obtain PA from MassHealth for any brand-name multiple-source drug that has an FDA
                              ”A”-rated generic equivalent as identified by the Approved Drug Products with Therapeutic Equivalence
                              Evaluations (also called the “Orange Book”). Additional information about which drugs require PA can be
                              found within the MassHealth Drug List at www.mass.gov/masshealth.



Member information
Last name                                First name                                     MI       MassHealth member ID No.        Date of birth    Sex (Circle one.)
                                                                                                                                                       f   m
Member’s place of residence                  home                  nursing facility



Medication information
 Brand-name drug requested                          Dose, frequency, and duration of brand-name drug                    Drug or service code

Diagnosis pertinent to requested medication

Has member tried a generic product?
   Yes. Provide the following information.                                                           No. Explain why not.
 Drug name

 Dates of generic use                            Dose and frequency

 Did member experience any of the following?
    Adverse reaction      Inadequate response          Other
    Details of adverse reaction, inadequate response, or other:




Pharmacy information
 Name                                                          Pharmacy provider no.             Telephone No.                   Fax No.
                                                                                      Optional   (        )                      (         )               Optional
Address                                                                                          City                            State           Zip
                                                                                                                                                           Optional




PA-5 (Rev. 07/08)                                                                                                                                           over 
Prescriber information
Last name                               First name                         MI      MassHealth provider no.    DEA No.

Address                                                                            City                       State         Zip

E-mail address                                                                     Telephone No.              Fax No.
                                                                        Optional   (      )                   (         )


Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification,
omission, or concealment of material fact may subject me to civil or criminal liability.


 Prescriber’s signature (Stamp not accepted.)                                                                                     Date
                                 Commonwealth of Massachusetts
                                 MassHealth Drug Utilization Review Program
                                 P.O. Box 2586
                                 Worcester, MA 01613-2586
                                 Fax: 1-877-208-7428 Phone: 1-800-745-7318

Drug Prior Authorization Request
                                 MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth
                                 approves the request, payment is still subject to all general conditions of MassHealth, including current
                                 member eligibility, other insurance, and program restrictions. MassHealth will notify the provider and member
                                 of its decision. Keep a copy of this form for your records. If faxing this form, please use black ink.
                                 Information about which drugs require PA can be found within the MassHealth Drug List at
                                 www.mass.gov/masshealth


Member information
Last name                                 First name                                  MI   MassHealth member ID no.      Date of birth     Sex (Circle one.)
                                                                                                                                               f    m
Member’s place of residence                  home                  nursing facility        Height                         Weight



Medication information
Drug name requested                            Dose, frequency, and duration                                   Drug NDC (if known) or service code

 Diagnosis and/or indication

 Goals of therapy for requested medication




 Has member tried other medications
 to treat this condition?                              Drug name

          Yes. Provide the information to the          Dates of use                                      Dose and frequency
          right. You may be asked to provide
          supporting documentation
                                                       Did member experience any of the following?
          (e.g., copies of medical records,
          office notes, and/or completed FDA             Adverse reaction                    Inadequate response                   Other
          MedWatch form).                                Briefly describe details of adverse reaction, inadequate response, or other.




          No. Explain why not.

                                                       Drug name

                                                       Dates of use                                      Dose and frequency

                                                       Did member experience any of the following?
                                                         Adverse reaction                    Inadequate response                   Other
                                                         Briefly describe details of adverse reaction, inadequate response, or other.




PA-2 (Rev. 07/08)                                                                                                                                    over 
Medication information (cont.)
Explain medical necessity of requested drug.




List all current medications.




Other pertinent information:




Diagnostic studies and/or laboratory tests performed (include dates and results)




Pharmacy information
Name                                                   Pharmacy provider no.        Telephone no.             Fax no.
                                                                        Optional    (      )                  (         )            Optional
Address                                                                             City                      State         Zip
                                                                                                                                     Optional



Prescriber information
Last name                               First name                         MI       MassHealth provider no.   DEA no.

Address                                                                             City                      State         Zip

E-mail address                                                                      Telephone no.             Fax no.
                                                                         Optional   (      )                  (         )


Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification,
omission, or concealment of material fact may subject me to civil or criminal liability.


Prescriber’s signature (Stamp not accepted.)                                                                                  Date
                                 Commonwealth of Massachusetts
                                 MassHealth Drug Utilization Review Program
                                 P.O. Box 2586
                                 Worcester, MA 01613-2586
                                 Fax: 1-877-208-7428 Phone: 1-800-745-7318
Suboxone/Subutex Prior Authorization Request
                                 MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth approves
                                 the request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other
                                 insurance, and program restrictions. MassHealth will notify the provider and member of its decision. Keep a copy of this
                                 form for your records. If faxing this form, please use black ink.
                                 PA is required for Subutex.
                                 PA is not required for Suboxone < 16mg day.
                                 PA is also required for Suboxone > 32mg/day and as indicated in the following chart.
                                          Dose                PA required after
                                  >24 and < 32 mg/day       3 months of therapy
                                  >16 and < 24 mg/day       6 months of therapy
                                 Information about the MassHealth Drug List can be found at www.mass.gov/druglist.

Member information
Last name                                    First name                               MI   MassHealth member ID no.        Date of birth   Sex (Circle one.)
                                                                                                                                               f    m
Member’s place of residence                     home               nursing facility


Medication information
Drug Name
   Subutex (buprenorphine)                      Suboxone (buprenorphine/naloxone)

Dose and frequency and duration of requested drug

Indication
   Opioid dependence                            Other (specify):

Taper schedule
Have you considered a taper schedule for this member?
   No.     If no, please provide medical necessity as to why a taper is not being considered
           at this point in time in the space provided along with complete treatment plan:
   Yes. If yes, please provide taper schedule below:




Section I: Please complete for Subutex requests.
1. Is the member pregnant?
      No      Yes. If yes, anticipated date of delivery:

 2. Does the member have a documented allergic reaction to naloxone?
      No     Yes. If yes, please provide medical records documenting the allergic reaction.

 3. If you answered “No” to the two questions above, what is the medical necessity for prescribing
    Subutex rather than Suboxone, for this member? (Please explain below.)




PA-23 (11/09)                                                                                                                                   over 
Medication information (cont.)
  Section II: Please complete for doses exceeding 24 mg/day.
  Please document medical necessity for high dose of Suboxone or Subutex below and submit medical records supporting the medical
  necessity provided.




  Note: A taper schedule is required for all requests for Suboxone or Subutex > 24 mg/day. Please document a taper schedule on the
  first page of this prior-authorization form.


  Section III: Please complete for concurrent fills of Suboxone or Subutex and a short-acting opioid.
  1. Are you the prescriber of both Suboxone or Subutex and the short-acting opioid?
        Yes       No

  2. Prior to continuing Suboxone or Subutex therapy, will the member be discontinuing the short-acting opioid(s)?
        Yes       No. If no, please answer questions 3 and 4 below.

  3. Please document the medical necessity for concurrent Suboxone or Subutex and short-acting opioid therapy. Please submit
     medical records supporting the medical necessity, including the specific pain that the current short-acting opioid is being
     used to treat.




  4. Please document the complete treatment plan, including expected duration of therapy for this member in regard to acute pain
     management with concurrent Suboxone or Subutex and short-acting opioid therapy.




Pharmacy information
 Name                                                         Pharmacy provider no.         Telephone no.                  Fax no.
                                                                                 Optional   (      )                       (         )            Optional
 Address                                                                                    City                           State         Zip
                                                                                                                                                  Optional



Prescriber information
 Last name                                First name                               MI       MassHealth provider no.        DEA no. (i.e., X number)




 E-mail address                                                                             Telephone no.                  Fax no.
                                                                                 Optional   (      )                       (         )

Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification, omission, or
concealment of material fact may subject me to civil or criminal liability.


 Prescriber’s signature (Stamp not accepted.)                                                                                            Date
                              Commonwealth of Massachusetts
                              MassHealth Drug Utilization Review Program
                              P.O. Box 2586
                              Worcester, MA 01613-2586
                              Fax: 1-877-208-7428 Phone: 1-800-745-7318

Trofile Assay and Selzentry (maraviroc) Prior Authorization Request
                               MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth approves
                               the request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other
                               insurance, and program restrictions. MassHealth will notify the provider and member of its decision. Keep a copy of this
                               form for your records. If faxing this form, please use black ink.

                               PA is required for all Selzentry (maraviroc) and Trofile Assay requests.

                               Information about the MassHealth Drug List can be found at www.mass.gov/druglist.


Member information
Last name                                First name                                   MI    MassHealth member ID no.     Date of birth   Sex (Circle one.)
                                                                                                                                             f    m
Member’s place of residence                    home                nursing facility



Medication information
   trofile assay                                          Selzentry (maraviroc)
                                                          (evidence of a positive assay is required for approval)

                                                      Dose, frequency, and duration



 Indication
   HIV-1                    Other (specify):

 Current viral load



 Section I
 1. Does your patient have treatment failure documented by an HIV-1 RNA > 5,000 copies/ml despite at least 6 months of prior therapy with at least
    one agent from three of the four antiretroviral categories listed below?

                            >1 nucleoside reverse transcriptase inhibitors (NRTI)
                            >1 non-nucleoside reverse transcriptase inhibitors (NNRTI)
                            >2 protease inhibitors (PI)
                            enfuvirtide (fusion inhibitor)


   yes     if no, - Please provide documentation of medical necessity or rationale for requested assay or medication.




PA-22 (12/07)                                                                                                                                 over 
  Section II
  Treatment Plan

  1. If requesting maraviroc, please provide results of trofile assay indicating positive CCR5-tropic HIV-1 infection.




  2. If requesting maraviroc, will concurrent antiretroviral therapy be prescribed?

               Yes. Please provide treatment regimen below.
               No. Please provide rationale why combination therapy is not indicated below.




Pharmacy information
 Name                                                           Pharmacy provider no.          Telephone no.               Fax no.
                                                                                    Optional   (      )                    (         )            Optional
 Address                                                                                       City                        State         Zip
                                                                                                                                                  Optional




Prescriber information
 Last name                                  First name                                MI       MassHealth provider no.     DEA no.

 Address                                                                                       City                        State         Zip

 E-mail address                                                                                Telephone no.               Fax no.
                                                                                    Optional   (      )                    (         )


Signature
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification, omission, or
concealment of material fact may subject me to civil or criminal liability.



 Prescriber’s signature (Stamp not accepted.)                                                                                            Date
                   Commonwealth of Massachusetts
                   Executive Office of Health and Human Services
                   www.mass.gov/masshealth


                       MassHealth Pharmacy Program Atypical Antipsychotic Initiative


1. Prior authorization (PA) is required for atypical antipsychotic medications exceeding the following quantity
   limits:

        Abilify (aripiprazole) – PA > 30 units/month
        Abilify (aripiprazole) liquid – PA > 750 ml/month
        Geodon (ziprasidone) – PA > 60 units/month
        Invega (paliperidone) – PA > 30 units/month
        Risperdal # (risperidone) – PA > 60 units/month
        Risperdal Consta (risperidone injection) – PA > two units (two syringes)/month
        Risperdal (risperidone) liquid – PA > 480 units/month
        Seroquel XR (quetiapine extended-release) 150 mg and 200mg – PA > 30 units/month
        Seroquel XR (quetiapine extended-release) 50 mg, 300 mg and 400 mg – PA > 60 units/month
        Zyprexa (olanzapine) – PA > 30 units/month

2. PA is required for most atypical antipsychotic duplicative therapy, which is defined as an overlap of 60 days
   or more in prescriptions (for any dosage form) of two or more of the following atypical antipsychotics.

        Abilify (aripiprazole)
        Geodon (ziprasidone)
        Invega (paliperidone)
        Risperdal (risperidone)
        Seroquel (quetiapine)
        Seroquel XR (quetiapine extended-release)
        Zyprexa (olanzapine)

3   Generic clozapine does not require PA when prescribed either alone or in concert with another atypical
    antipsychotic. Brand name Clozaril requires PA because it has an FDA “A”-rated generic equivalent.

4. Abilify IM (aripiprazole injection), Geodon IM (ziprasidone injection), and Risperdal Consta (risperidone
   injection) do not require PA for duplicative therapy when prescribed in combination with another atypical
   antipsychotic. However, if Risperdal Consta exceeds two units (two syringes) per month, PA would be
   required for exceeding quantity limits.

5. The following atypical antipsychotics require PA:

        Abilify Discmelt (aripiprazole, orally disintegrating tablet ) – PA
        Fazaclo (clozapine, orally disintegrating tablet) – PA
        Risperdal M (risperidone, orally disintegrating tablet) – PA
        Symbyax (fluoxetine/olanzapine) – PA
        Zyprexa Zydis (olanzapine, orally disintegrating tablet) – PA
        Zyprexa IM (olanzapine injection) – PA
MassHealth encourages prescribers to use the Antipsychotic Prior Authorization Request form when requesting PA for any of the
above antipsychotics. See the Atypical Antipsychotics Table for more information about selected antipsychotics.

* Note: The decision on whether PA is required is based upon information available in the MassHealth pharmacy database.
The MassHealth database contains member drug utilization information exclusive to MassHealth, and no other health plans.

August 3, 2009
                        Commonwealth of Massachusetts
                        Executive Office of Health and Human Services
                        www.mass.gov/druglist

                                        MassHealth Pharmacy Program Pain Initiative
A. Schedule II Narcotic Analgesics                                                 oxymorphone extended-release (Opana ER) – PA
                                                                                   (See Note above if > 120 mg/day.)
    1. The following Schedule II long-acting narcotic                              tapentadol (Nucynta) – PA
       analgesics require prior authorization (PA) for the
       doses indicated.                                                     C. Opioid Therapy Algorithm

            levorphanol (Levo-Dromoran#) – PA > 32 mg/day                        The opioid therapy algorithm is intended as a guide for
            methadone (Dolophine#, Methadose) – PA > 120                         providers when prescribing narcotic analgesics. Please
              mg/day                                                             consider this algorithm when beginning or changing
            morphine controlled-release (MS Contin #,                            narcotic analgesics for MassHealth members.
              Oramorph SR, generics) – PA > 360 mg/day
                                                                                 Step 1: non-narcotic analgesics -NSAIDS/Acetaminophen
    2. The following Schedule II short-acting narcotic                                   – If neuropathic pain, consider tricyclic
       analgesics require PA for the doses indicated.                                    antidepressants (TCAs), anticonvulsants
                                                                                 Step 2: short-acting narcotic analgesics (acute pain)
            codeine – PA > 360 mg/day                                            Step 3: long-acting morphine SR
            hydromorphone (Dilaudid #) – PA > 60 mg/day                          Step 4: methadone (if clinically appropriate)
            morphine immediate release (MS/L, MSIR, OMS,                         Step 5: oxycodone CR
              Roxanol, Roxanol-T) – PA > 360mg/day                               Step 6: fentanyl
            oxycodone immediate release (Endocodone,                             Step 7: oxymorphone
              Oxydose, OxyFast, OxyIR, Roxicodone) –
              PA > 240 mg/day                                               D. Duplicate Narcotic Therapy
B. Narcotic Analgesics That Require PA for All Dosage                            PA is required for members taking > two long-acting
   Forms and Strengths                                                           narcotics for > three months.
    Note: Additional information is required for narcotic
          requests that exceed dose or quantity limits. Please
          provide medical records and complete Section III
          of the Narcotic Prior Authorization Request form
          when requesting PA for quantities or doses in
          excess of the limits listed below.

       fentanyl buccal film (Onsolis) – PA
       fentanyl transmucosal system (Actiq, Fentora) – PA
       fentanyl transdermal system (Duragesic) – PA (See
         Note above if > 200 mcg/hour.)
       meperidine (Demerol) – PA (See Note above if > 750
         mg/day.)
       morphine extended-release (Avinza) – PA (See Note
         above if > 360 mg/day.)
       morphine/naloxone (Embeda) – PA (See note above if
         > 360 mg/day)
       morphine sustained-release (Kadian) – PA (See note
         above if > 360 mg/day)
       narcotic powders (hydromorphone, levorphanol,
         methadone, morphine, oxycodone) – PA
       oxycodone controlled release (OxyContin, generics) –
         PA (See Note above if > 240 mg/day.)
       oxymorphone immediate release (Opana) – PA (See
         Note above if > 120 mg/day.)



# This is a brand-name drug with FDA “A” rated-generic equivalents. PA is required for the brand, unless a particular form of that drug does not
  have an FDA “A” rated generic equivalent.
May 3, 2010
                                                                                                MassHealth Quick Reference Guide

Alpha-1 Adrenergic Blockers         Cozaar—PA                            Gabitril—PA > 18 yrs.         Aplenzin—PA                 Antipsychotics        Tilade                        omeprazole 40mg—PA
doxazosin                           Diovan—PA                            Keppra XR—PA                  Cymbalta—PA                 clozapine             Vanceril                      pantoprazole—PA
                                                                                                                                              1
prazosin                            Micardis—PA                          Lyrica—PA                     Effexor XR—PA               risperidone —Q        Ventolin HFA—PA               Aciphex—PA
                                                                                                                                           1
terazosin                           Teveten—PA                           Mebaral                       Lexapro—PA                  Abilify —Q            Xopenex—PA                    Dexilant—PA
Flomax—PA                                                                Peganone                      Luvox CR—PA                 Abilify Discmelt—PA                                 Nexium—PA
                                                                                                                                          1
Rapaflo—PA                          Anticonvulsants                      Sabril—PA                     Pexeva—PA                   Fanapt —PA            Hypnotics                     Onsolis—PA
Uroxatral—PA                        carbamazepine                        Stavzor—PA                    Pristiq—PA                  Fazaclo—PA            estazolam—Q                   Prilosec—PA
                                                                                                                                           1
                                    clonazepam                           Vimpat tablets—PA             Wellbutrin XL—PA            Geodon —Q             flurazepam—Q                  Protonix—PA
                                                                                                                                         1
Angiotensin Converting              clorazepate                                                                                    Invega —PA            temazepam—Q
Enzyme Inhibitors                   diazepam                             Antidepressants               Antidiabetic Agents         Invega Sustenna—Q     temazepam 22.5mg—PA           Statins
benazepril                          divalproex                           bupropion                     acarbose                    Risperdal M—PA        triazolam—Q                   lovastatin—Q
captopril                           ethosuximide                         bupropion SR                  acetohexamide               Risperdal Consta—Q    zaleplon—Q                    pravastatin—Q
                                                                                                                                          1
enalapril                           gabapentin                           bupropion XL—PA               chlorpropamide              Saphris —PA           zolpidem—Q                    simvastatin—Q
                                                                                                                                            1
fosinopril                          lamotrigine                          citalopram                    glimepiride                 Seroquel —Q           Ambien CR—PA                  Advicor—PA
                                                                                                                                               1
lisinopril                          levetiracetam                        fluoxetine 10 mg/20 mg        glipizide                   Seroquel XR —Q        Doral—PA                      Altoprev—PA
                                                                                                                                           1
moexipril                           oxcarbazepine                        capsules                      glipizide ER                Zyprexa —Q            Edluar—PA                     Crestor—PA
quinapril                           phenobarbital                        fluoxetine—PA 20 mg tablets   glyburide                   Zyprexa IM            Lunesta—PA                    Lescol—PA
ramipril                            phenytoin                            and 40 mg capsules            metformin                   Zyprexa Relprevv—Q    Restoril 7.5 mg—PA            Lescol XL—PA
trandolapril                        primidone                            MAOIs                         metformin ER                Zyprexa Zydis—PA                                    Lipitor—PA
Aceon—PA                            topiramate—PA > 18 yrs.              maprotiline                   tolazamide                                        Leukotrienes                  Simcor—PA
Altace—PA                           valproate                            mirtazapine                   tolbutamide                 Asthma                Accolate—PA
                                    valproic acid                        mirtazapine ODT—PA            Actos                       albuterol             Singulair—PA                  Triptans
Angiotensin II Receptor             zonisamide                           nefazodone                    Avandia                     metaproterenol        Zyflo CR—PA                   sumatriptan Inj.—PA
Antagonists                         Banzel—PA                            paroxetine                    Diabeta—PA                  Advair—PA                                           sumatriptan tab—Q
Atacand—PA                          Celontin                             paroxetine CR—PA              Fortamet—PA                 Aerobid               Narcotic Agonist Analgesics   Amerge—PA
Avapro—PA                           Dilantin                             sertraline                    Glyset—PA                   Aerobid-M             fentanyl patch—PA             Axert—PA
Benicar—PA                          Felbatol                             TCAs                          Insulin, Prefilled Syr—PA   Alupent—PA            levorphanol—Q                 Frova—PA
                                                                         trazodone                     Januvia—PA                  Alvesco               methadone—Q                   Imitrex Nasal—PA
May 2010                                                                 venlafaxine                   Prandin—PA                  Atrovent #            morphine CR—Q                 Maxalt—PA
                                                                                                       Starlix—PA                  Azmacort              morphine SR—PA                Relpax—PA
 This document does not represent the complete MassHealth Drug List. For more information, please      Victoza—PA                  Brovana—PA            oxycodone ER—PA               Treximet—PA
 visit the MassHealth Web site at www.mass.gov/druglist.
                                                                                                                                   Combivent             Embeda—PA                     Zomig—PA
 MassHealth evaluates the prior-authorization status of drugs on an ongoing basis, and updates the     Antihistamines              Flovent               Onsolis—PA                    Zomig ZMT—PA
 MassHealth Drug List accordingly.                                                                     brompheniramine             Foradil—PA            Nucynta —PA                   PA > 9 units/month for sumat-
                                                                                                       cetirizine                  Maxair—PA             Opana—PA                      riptan tab.
 1
     = PA required for polypharmacy (overlap of more than 60 days).
                                                                                                       chlorpheniramine            ProAir HFA
 # = This is a brand-name drug with FDA “A”-rated generic equivalents. PA is required for the brand,   diphenhydramine             Proventil HFA—PA      Proton Pump Inhibitors
 unless a particular form of that drug does not have an FDA “A”-rated generic equivalent.
                                                                                                       fexofenadine—PA             Pulmicort             lansoprazole—PA > 2 yrs.
 PA = Prior authorization required. Prior-authorization forms can be found at www.mass.gov/druglist.   loratadine                  Qvar                  omeprazole 10mg/20mg
                                                                                                       Clarinex—PA                 Serevent—PA
 Q = PA is required to exceed certain quantity limits.                                                 Xyzal—PA                    Symbicort—PA
                                     MassHealth Over-the-Counter Drug List

This page lists the only over-the-counter (OTC) drugs that are covered by MassHealth without prior authorization (PA). All other
OTC drugs except insulins require PA. Please refer to 130 CMR 406.411(A) and 406.412(A)(2) for further information on OTC
drugs.

Insulins that are available without PA are listed in the MassHealth Drug List. All insulins are covered for members at home, in
nursing facilities, or in rest homes.

The items are listed alphabetically by therapeutic class, then by the generic name of the drug or drug ingredients. In general,
MassHealth pays only for generic versions of these OTC drugs, singly or in combination, regardless of strength or dosage form.
Combination products that contain active ingredients that are not included in this list
require PA.

Notwithstanding the above, MassHealth may pay for a brand-name OTC product if that product meets the definition of medical
necessity at 130 CMR 406.204. Any such product for which payment is permitted appears on this list by brand name.


Allergy Agents, Ophthalmic:                  aluminum hydroxide                            retinol (vitamin A)
Alaway (ketotifen)                           bisacodyl                                     riboflavin
ketotifen                                    bismuth subsalicylate                         thiamine
Naphcon-A (naphazoline/                      calcium carbonate                             vitamin B complex
  pheniramine)                               casanthranol                                  vitamin D
Opcon-A (naphazoline/                        cimetidine                                    vitamin E, oral
  pheniramine)                               cod liver oil
Vasocon-A (naphazoline/                      Culturelle (lactobacillus rhamnosus           Miscellaneous Products:
atazoline)                                     GG) < 18 years                              A&D ointment
Visine-A (naphazoline/                       docusate sodium                               ammonium lactate 12%
  pheniramine)                               famotidine                                    artificial tears
                                             glycerin                                      benzoyl peroxide (under 21
Analgesics:                                  kaolin/pectin                                   years old)
acetaminophen                                loperamide                                    calamine lotion carbamide peroxide
aspirin                                      magaldrate                                    cherry syrup
aspirin with buffers                         magnesium citrate                             coenzyme Q10 < 18 years
capsaicin                                    magnesium hydroxide                           colloidal oatmeal Commit (nicotine)
ibuprofen                                    magnesium trisalicylate                         < 90 days/treatment regimen and
naproxen                                     meclizine mineral oil                           < two treatment regimens/year
                                             psyllium                                      hydrocortisone
Antihistamines/ Decongestants:               ranitidine                                    hydrophilic ointment
brompheniramine                              senna                                         lanolin
cetirizine syrup, tablet                     simethicone                                   nicotine – < 90 days/treatment
chlorpheniramine                             sodium bicarbonate                              regimen and < two treatment
diphenhydramine                                                                              regimens/year
loratadine                                   Vitamins and Nutrients:                       Ora-Plus suspending vehicle
pseudoephedrine < 240 mg/day                 ascorbic acid                                 Ora-Sweet-SF syrup
                                             calcium carbonate                             Ora-Sweet oral syrup
Antimicrobials, Topical:                     calcium citrate                               permethrin
bacitracin                                   calcium glubionate                            petrolatum
chlorhexidine gluconate                      calcium gluconate                             piperonyl butoxide
clotrimazole                                 calcium phosphate                             Plan B (levonorgestrel)
hydrogen peroxide                            cyanocobalamin                                Plan B One Step (levonorgestrel)
iodine                                       electrolyte solution (pediatric)              potassium phosphate
isopropyl alcohol                            ferrous fumarate                              pyrethrum
miconazole                                   ferrous gluconate                             saliva substitute
neomycin                                     ferrous sulfate                               selenium sulfide
polymixin B                                  folic acid                                    simple syrup
povidone                                     magnesium gluconate                           sodium chloride solution
tolnaftate                                   multivitamins, N.F.                             for inhalation
triple antibiotic ointment                   multivitamins with minerals                   sodium phosphate
                                             niacin                                        water for inhalation
Contraceptives, Topical:                     niacinamide                                   witch hazel
nonoxynol-9                                  nicotinic acid                                zinc oxide
                                             pediatric vitamins
Gastrointestinal Products:                   prenatal vitamins
aluminum carbonate                           pyridoxine (vitamin B6)
                                                                                                                          May 3, 2010
                              MassHealth Non-Drug Product List

This page lists the non-drug products that MassHealth pays for through the Pharmacy Online
Processing System (POPS). Products that require prior authorization are noted with the
designation PA. Payment is calculated in accordance with the Division of Health Care Finance
and Policy’s regulations at 114.3 CMR 22.00: Durable Medical Equipment and 114.3 CMR
17.00: Medicine.

Medical Supplies
Alcohol swabs
Freestyle, Freestyle Light and Precision Xtra brand blood glucose testing reagent strips used for
    the management of diabetes – PA > 100 units/month (effective 4/1/2010)
All other brands of blood glucose testing reagent strips used for the management of diabetes – PA
    (effective 4/1/2010)
Urine glucose testing reagent strips used for the management of diabetes
Disposable insulin syringe and needle units
Lancets

Devices
Drug delivery systems for use with metered dose inhalers (for example, aerochambers)
Euflexxa (hyaluronate) – PA
Hyalgan (hyaluronate) – PA
Hyper-Sal (sodium chloride 7% for inhalation)
Insulin cartridge delivery devices and needles or other devices for injection of medication (for
    example, Epipens)
Orthovisc (hyaluronan) – PA
Supartz (hyaluronate) – PA
Synvisc (hylan polymers) – PA




March 1, 2010
                                 10 Tips for a Good Night’s Sleep
1. Keep consistent bedtimes and wake times seven days a week (even after a "bad" night).

2. A person should only stay in bed equal to the number of hours of sleep they are achieving per night (for
example, if you are getting six hours of sleep per night you should plan bedtime and wake time as six hours
apart). Many insomniacs spend far too much time in bed, attempting to "squeeze" out a few more
minutes of sleep.

3. If you have difficulty getting to sleep within 20 minutes, get out of bed and do something relaxing and
distracting. For many people this is reading. Do not do housework, bills, work, or anything that is too
stimulating within two hours of bedtime or during a nighttime awakening.

4. Although some people's insomnia is helped by a nap at midday, for most, it will interfere with falling
asleep that night.

5. Avoid alcohol within five hours of bedtime. Alcohol is a poor hypnotic and causes nighttime
awakenings.

6. Avoid caffeine (coffee, tea, soda, chocolate) after noon. Even if it doesn't prevent you from falling
asleep, it can cause shallow sleep or nighttime awakenings.

7. Avoid going to bed on either an empty stomach or a full stomach. A light snack may be of value.

8. Bedrooms should be quiet, safe, and relaxing. Clocks should face away from the bed, so as not to
"count down" the minutes until morning.

9. Daily exercise will improve insomnia, although the effects may not be immediate.

10. Schedule "worry time" earlier in the day, so as to consider the day's problems and find some resolution
before getting into bed.

John Winkelman, MD, PhD
Medical Director, Sleep Health Center
Brigham and Women’s Hospital
Assistant Professor of Psychiatry
Harvard Medical School




03/03/03
The MassHealth Drug List is updated monthly, as needed.
Check our Web site for the most up-to-date information.
              www.mass.gov/druglist




               Commonwealth of Massachusetts
        Executive Office of Health and Human Services
                         MassHealth

								
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