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Number 106 September 21, 2017 Page 1 of 2

www.mass.gov/masshealth/pharmacy • Editor: Vic Vangel • Contributors: Paul Jeffrey, Kim Lenz, Nancy Schiff, Vic Vangel •

MHDL Update  Namenda (memantine titration pack) – Below are certain updates to the MassHealth Drug PA < 18 years and PA > 49 units/ month List (MHDL). See the MHDL for a complete list of  Razadyne # (galantamine tablet) – PA updates. < 18 years and PA > 60 units/month 1. Additions  Razadyne ER # (galantamine extended-release capsule) – PA < 18 Effective September 25, 2017, the following newly years and PA > 30 units/month marketed drugs have been added to the MassHealth Drug List.  rivastigmine capsule – PA < 18 years and PA > 60 units/month  Alunbrig (brigatinib) – PA c. Effective September 25, 2017, the following  Kevzara (sarilumab) – PA thalidomide analogue will require prior  Renflexis (infliximab-abda) – PA authorization for all quantities.  Rituxan Hycela (rituximab/hyaluronidase  Revlimid (lenalidomide) – PA human) – PA d. Effective September 25, 2017, the following  Rydapt (midostaurin) – PA anesthetic will no longer require prior  Totect (dexrazoxane) authorization and will no longer be restricted  Xadago (safinamide) – PA to the health care professional who administers the drug. This anesthetic will be 2. Change in Prior-Authorization Status available only in an inpatient hospital setting. a. Effective September 25, 2017, the following  Ketalar (ketamine injection) H Alzheimer’s agents will require prior e. Effective September 25, 2017, the following authorization for all quantities. ophthalmic anti-allergy and anti- inflammatory agent will no longer require  Exelon (rivastigmine patch) – PA prior authorization.  galantamine solution – PA  azelastine ophthalmic solution f. Effective September 25, 2017, the following  Namenda (memantine solution) – PA Monoamine Oxidase (MAO) Type-B b. Effective September 25, 2017, the Inhibitor will no longer require prior following Alzheimer’s agents will require authorization. prior authorization when used outside of  selegiline capsule newly established age limits. g. Effective September 25, 2017, the following  Aricept # (donepezil 10 mg tablet) – PA skeletal muscle relaxant agents will require < 18 years and PA > 60 units/month prior authorization when used outside of  Aricept # (donepezil 5 mg tablet) – PA newly established age limits. < 18 years and PA > 30 units/month  cyclobenzaprine 5 mg, 10 mg – PA <  donepezil orally disintegrating tablet – 15 years PA < 18 years and PA > 30 units/  orphenadrine – PA < 18 years month  Parafon Forte DSC # (chlorzoxazone  Namenda # (memantine tablet) – PA < 500 mg) – PA < 18 years 18 years and PA > 60 units/month  Robaxin # (methocarbamol) – PA < 16 years Pharmacy Facts, NumberPage 2 of106 2

1. Updated MassHealth Brand Name Preferred Legend Over Generic Drug List a. Effective September 25, 2017, the following PA Prior authorization is required. The prescriber If antiplatelet agent will be added to the must obtain prior authorization for the drug in MassHealth Brand Name Preferred Over order for the pharmacy to receive payment. Generic Drug List. Note: Prior authorization applies to both the  Effient (prasugrel) BP – PA brand-name and the FDA “A”-rated generic equivalent of listed product. b. Effective September 25, 2017, the following anticonvulsant agent will be added to the # This designates a brand-name drug with FDA MassHealth Brand Name Preferred Over “A”-rated generic equivalents. Prior Generic Drug List. authorization is required for the brand, BP  Sabril (vigabatrin) – PA unless a particular form of that drug (for c. Effective September 25, 2017, the following example, tablet, capsule, or liquid) does not phosphate binding agent will be added to have an FDA “A”-rated generic equivalent. the MassHealth Brand Name Preferred Over Generic Drug List. BP Brand Preferred over generic equivalents. In  Fosrenol (lanthanum) BP general, MassHealth requires a trial of the d. Effective September 25, 2017, the following preferred drug or clinical rationale for benzodiazepine agent will be removed from prescribing the nonpreferred drug generic the MassHealth Brand Name Preferred equivalent. Over Generic Drug List. H Available only in an inpatient hospital setting.  Diastat (diazepam rectal gel) – PA > 5 MassHealth does not pay for this drug to be kits (10 syringes)/month dispensed through the retail pharmacy or e. Effective September 25, 2017, the following physician's office. antiprotozoal agent will be removed from the MassHealth Brand Name Preferred * The generic OTC and, if any, generic prescription Over Generic Drug List. versions of the drug are payable under  Mepron # (atovaquone) MassHealth without prior authorization. f. Effective September 25, 2017, the following antidepressant agent will be removed from ̂ This drug is available through the health care the MassHealth Brand Name Preferred professional who administers the drug. Over Generic Drug List. MassHealth does not pay for this drug to be  Pristiq (desvenlafaxine succinate dispensed through a retail pharmacy. extended-release) – PA g. Effective September 25, 2017, the following nonstimulant ADHD agent will be removed from the MassHealth Brand Name Preferred Over Generic Drug List.  Strattera # (atomoxetine) – PA < 6 years

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