Number 107 November 3, 2017

MHDL Update  Aptensio XR (methylphenidate extended-release) – PA Below are certain updates to the MassHealth  Daytrana (methylphenidate Drug List (MHDL). See the MHDL for a complete transdermal) – PA listing of updates.  Metadate CD (methylphenidate

Effective November 6, 2017, the following newly extended-release) – PA marketed drugs have been added to the  Quillichew ER (methylphenidate MassHealth Drug List. extended-release chewable tablet) – PA  Aristada (aripiprazole lauroxil 1,064 mg) – PA < 6 years and PA > 1 injection/2 months  Ritalin LA (methylphenidate extended- release) – PA  Carospir (spironolactone suspension) – PA d. Effective November 6, 2017, the following  Cotempla XR-ODT (methylphenidate atypical antipsychotic agent will no longer extended-release orally disintegrating tablet) require prior authorization within updated – PA age limits.  Haegarda (c1 esterase inhibitor, human) – PA  Abilify # (aripiprazole tablet) – PA < 6  Idhifa (enasidenib) – PA years and PA > 30 units/month  Mydayis (amphetamine salts extended- e. Effective November 6, 2017, the following release) – PA chemotherapy agent will be available only  Nerlynx (neratinib) – PA in an inpatient hospital setting.  Radicava (edaravone) – PA  Thiotepa H  Tremfya (guselkumab) – PA Updated MassHealth Brand Name Change in Prior-Authorization Status Preferred Over Generic Drug List a. Effective November 6, 2017, the following a. Effective November 6, 2017, the following cardiovascular agents will no longer long-acting amphetamine cerebral require prior authorization. stimulant agent will be added to the  Exforge # (amlodipine/valsartan) MassHealth Brand Name Preferred Over  Lotrel # (amlodipine/benazepril) Generic Drug List. b. Effective November 6, 2017, the following  Adderall XR (amphetamine salts cardiovascular agents will require prior extended-release) BP PD – PA < 3 authorization. years and PA > 60 units/month  Edecrin (ethacrynic acid) – PA b. Effective November 6, 2017, the following  Isordil (isosorbide dinitrate 40 mg antiretroviral agents will be added to the tablet) – PA MassHealth Brand Name Preferred Over c. Effective November 6, 2017, the following Generic Drug List. long-acting stimulants will require prior  Lexiva (fosamprenavir) BP authorization for all ages and quantities.  Prezista (darunavir) BP

Pharmacy Facts, Number 107 Page 2 of 2

 Reyataz (atazanavir) BP  Focalin XR (dexmethylphenidate  Sustiva (efavirenz) BP extended-release) BP PD – PA < 3  Truvada (emtricitabine/tenofovir years and PA > 60 units/month disoproxil fumarate) BP c. Effective November 6, 2017, the following c. Effective November 6, 2017, the following Anti-TNF agents will be added to the ammonia inhibitor agent will be added to MassHealth Supplemental Rebate/ the MassHealth Brand Name Preferred Preferred Drug List. Over Generic Drug List.  Enbrel (etanercept) PD – PA  Buphenyl (sodium phenylbutyrate  Humira (adalimumab) PD – PA tablet) BP d. Effective November 6, 2017, the following d. Effective November 6, 2017, the following antiretroviral agents will be added to the multiple sclerosis agents will be added to MassHealth Supplemental Rebate/ the MassHealth Brand Name Preferred Preferred Drug List. Over Generic Drug List. BP  Descovy (emtricitabine/tenofovir  Copaxone (glatiramer 40 mg) PD alafenamide) e. Effective November 6, 2017, the following  Genvoya (elvitegravir/cobicistat/ lipid lowering agent will be removed from emtricitabine/tenofovir alafenamide) PD the MassHealth Brand Name Preferred  Norvir (ritonavir) BP PD Over Generic Drug List.  Odefsey (emtricitabine/rilpivirine/  Zetia (ezetimibe) – PA tenofovir alafenamide) PD f. Effective November 6, 2017, the following

dermatological agent will be added to the

MassHealth Brand Name Preferred Over

Generic Drug List. ______ Aczone (dapsone gel) BP– PA Legend

Updated MassHealth Supplemental PA Prior authorization is required. The prescriber must obtain Rebate/Preferred Drug List prior authorization for the drug in order for the pharmacy to receive payment. Note: PA applies to both the brand- a. Effective November 6, 2017, the following name and the FDA “A”-rated generic equivalent of listed long-acting amphetamine cerebral product.

stimulant agents will be added to the # Designates a brand-name drug with FDA “A”-rated MassHealth Supplemental generic equivalents. Prior authorization is required for the Rebate/Preferred Drug List. brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated  Adderall XR (amphetamine salts generic equivalent. extended-release) PD – PA < 3 years BP Brand preferred over generic equivalents. In general, and PA > 60 units/month MassHealth requires a trial of the preferred drug or  Vyvanse (lisdexamfetamine) PD – PA < clinical rationale for prescribing the nonpreferred drug generic equivalent. 3 years and PA > 60 units/month

b. Effective November 6, 2017, the following H Available only in an inpatient hospital setting. MassHealth long-acting methylphenidate cerebral does not pay for this drug to be dispensed through the stimulant agent will be added to the retail pharmacy or physician's office.

MassHealth Supplemental Rebate/ PD In general, MassHealth requires a trial of the preferred Preferred Drug List. drug (PD) or a clinical rationale for prescribing a nonpreferred drug within a therapeutic class.

If you have questions or comments, or want to be removed from this fax distribution, please contact Victor Moquin at Conduent at 617-423-9830.