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• Editor: Vic Vangel • Contributors: Paul Jeffrey, Kim Lenz, James Monahan, Nancy Schiff •

MHDL Update Change in Prior Authorization Status, cont’d

1. Additions d. Effective October 31, 2016, the following antidepressant agents will no longer Effective October 31, 2016, the following require prior authorization within age newly marketed drugs have been added to limits. Pediatric Behavioral Health the MassHealth Drug List. Medication Initiative criteria will still Afstyla (antihemophilic factor, apply. For additional information, please recombinant, single chain) see the Pediatric Behavioral Health Briviact (brivaracetam solution, tablet) – Medication Initiative documents found at PA www.mass.gov/druglist. butalbital 25 mg/acetaminophen 325 mg Cymbalta # (duloxetine 20 mg, 30 mg, tablet – PA 60 mg) – PA < 6 years Byvalson (nebivolol/valsartan) – PA Prozac # (fluoxetine 40 mg capsule) – Cabometyx (cabozantinib tablet) – PA PA < 6 years Cinqair (reslizumab) – PA Levo-T # (levothyroxine) e. Effective October 31, 2016, the following Nuplazid (pimavanserin) – PA topical anesthetic agent will no longer Ocaliva (obeticholic acid) – PA require prior authorization within quantity Onzetra (sumatriptan nasal powder) – PA limits. Probuphine (buprenorphine implant)^ – PA Qbrelis (lisinopril solution) – PA Lidoderm # (lidocaine patch) – PA > 90 Tecentriq (atezolizumab) – PA patches/mo.

Vaxchora (cholera vaccine, live, oral)1 f. Effective October 31, 2016, the following Venclexta (venetoclax) – PA lipid lowering agent will no longer require Viekira XR prior authorization within quantity limits. (dasabuvir/ombitasvir/paritaprevir/ritonavir extended-release) – PA Crestor # (rosuvastatin 5 mg, 10 mg, 20 Vonvendi (von willebrand factor, mg) – PA > 45 units/mo. recombinant) Crestor # (rosuvastatin 40 mg) – PA > 30 Xtampza (oxycodone extended-release units/mo. capsule) – PA Zembrace (sumatriptan injection) – PA g. Effective October 31, 2016, the following Zinbryta (daclizumab) – PA non-stimulant Attention Deficit Hyperactivity Disorder (ADHD) agent will 2. Change in Prior Authorization Status no longer require prior authorization within age limits. Pediatric Behavioral a. Effective October 31, 2016, the chewable Health Medication Initiative criteria will tablet and oral suspension formulations of still apply. For additional information, the following antiviral agent will no longer please see the Pediatric Behavioral require prior authorization. Health Medication Initiative documents Isentress (raltegravir) found at www.mass.gov/druglist. Intuniv # (guanfacine extended-release) b. Effective October 31, 2016, the following – PA < 3 years immunosuppressant will no longer require h. Effective October 31, 2016, the following prior authorization. proton pump inhibitor will no longer Envarsus XR (tacrolimus extended- require prior authorization within quantity release tablet) limits. c. Effective October 31, 2016, the following omeprazole 40 mg – PA > 60 units/mo. phosphate binding agents will no longer i. Effective October 31, 2016, the following require prior authorization. H2 antagonist will require prior Auryxia (ferric citrate) authorization. Fosrenol (lanthanum) Pepcid (famotidine suspension) – PA Velphoro (sucroferric oxyhydroxide)

j. Effective October 31, 2016, the following topical anesthetic agent will require prior authorization.

lidocaine ointment – PA

MHDL Update, cont’d

3. MassHealth Supplemental 6. Corrections / Clarifications Rebate/Preferred Drug List The following drugs have been added to the Effective October 31, 2016, the following MassHealth Drug List. hepatitis antiviral combination agent will be added to the MassHealth Supplemental Dekas Essential (multivitamin) – PA Rebate/Preferred Drug List. Dekas Plus (multivitamins/minerals/coenzyme Q10) Epclusa (sofosbuvir/velpatasvir) PD – PA – PA Dekas Plus (multivitamins/minerals/folic 4. Updated MassHealth Non-Drug acid/coenzyme Q10) – PA Product List Egrifta (tesamorelin) – PA

Effective October 31, 2016, the following device has been added to the MassHealth PA Prior authorization is required. The prescriber must obtain prior authorization Non-Drug Product List requiring prior for the drug in order for the pharmacy to authorization. receive payment. Note: Prior authorization Gelsyn (hyaluronate) – PA applies to both the brand-name and the FDA “A”-rated generic equivalent of listed 5. MassHealth Brand Name Preferred product. over Generic Drug List # This designates a brand-name drug with a. Effective October 31, 2016, the following FDA “A”-rated generic equivalents. Prior opioid agent will be added to the authorization is required for the brand, MassHealth Brand Name Preferred Over unless a particular form of that drug (for Generic Drug List. example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic Oxycontin (oxycodone extended-release equivalent. tablet)BP – PA ^ This drug is available through the health care professional who administers the drug. MassHealth does not pay for this b. Effective October 31, 2016, the following drug to be dispensed through a retail pharmacy. cerebral stimulant agent will be removed from the MassHealth Brand Name Preferred Over Generic Drug List.

Adderall XR (amphetamine salts extended-release) – PA < 3 years and PA > 60 units/mo.

Please direct any questions or comments (or to be taken off of this fax distribution) to Victor Moquin of Xerox at 617-423-9830.