Number 91 January 26, 2016

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

MHDL Update 2. Change in Prior Authorization Status

Below are certain updates to the MassHealth Drug a. Effective February 8, 2016, the following headache List (MHDL). See the MHDL for a complete listing of therapy agent will no longer require prior updates. authorization within quantity limits.

1. Additions Maxalt MLT # (rizatriptan orally disintegrating tablet) – PA > 18 units/month Effective February 8, 2016, the following newly marketed drugs have been added to the MassHealth b. Effective February 8, 2016, the following leukotriene Drug List. modifiers will no longer require prior authorization.

Aptensio XR (methylphenidate extended-release) – Singulair # (montelukast tablet, chewable tablet) PA < 3 years and PA > 30 units/month Asmanex HFA (mometasone inhalation aerosol) c. Effective February 8, 2016, the following colony Corlanor (ivabradine) – PA stimulating factor will no longer require prior Daklinza (daclatasvir) – PA authorization. Duopa (carbidopa/levodopa enteral suspension) – PA Entresto (sacubitril/valsartan) – PA Neupogen (filgrastim) Farydak (panobinostat) – PA Finacea (azelaic acid foam) – PA d. Effective February 8, 2016, the following opioid Invega Trinza (paliperidone extended-release 3-month dependence agent will no longer require prior injection) – PA < 6 years and PA > 1 unit/3 months authorization within dose and duration of therapy Namzaric (memantine extended-release/donepezil) – limits. PA Natpara (parathyroid hormone) – PA Suboxone (buprenorphine/naloxone film ≤ 16 Opdivo (nivolumab) – PA mg/day) Orkambi (lumacaftor/ivacaftor) – PA Suboxone (buprenorphine/naloxone film) – phenoxybenzamine – PA PA > 180 days (> 16 mg/day and ≤ 24 mg/day) Praluent (alirocumab) – PA Suboxone (buprenorphine/naloxone film) – Proair Respiclick (albuterol inhalation powder) – PA PA > 90 days (> 24 mg/day and ≤ 32 mg/day) Repatha (evolocumab) – PA Suboxone (buprenorphine/naloxone film) – Rexulti (brexpiprazole) – PA PA > 32 mg/day Stiolto (tiotropium/olodaterol) – PA Synjardy (empagliflozin/metformin) – PA e. Effective March 7, 2016, the following nonsteroidal Technivie (ombitasvir/paritaprevir/ritonavir) – PA anti-inflammatory agents will require prior Tivorbex (indomethacin 20 mg, 40 mg) – PA authorization. Zarxio (filgrastim-sndz) Zecuity (sumatriptan iontophoretic transdermal system) diflunisal – PA – PA fenoprofen 600 mg – PA Zingo (lidocaine powder intradermal injection system) – salsalate – PA PA f. Effective March 7, 2016, the following opioid analgesic will require prior authorization.

Buprenex (buprenorphine injection) – PA

Pharmacy Facts, Number 91 Page 2 of 2

Duramorph (morphine, injection) – PA > 120 g. Effective March 7, 2016, the following topical mg/day antibiotic will require prior authorization. hydrocodone/acetaminophen – PA > 80 mg/day levorphanol tablet – PA > 4 mg/day Evoclin (clindamycin foam) – PA morphine immediate-release – PA > 120 mg/day MS Contin # (morphine controlled-release tablet) – h. Effective March 7, 2016, the following antimalarial PA > 120 mg/day agent will require prior authorization. oxycodone/acetaminophen – PA > 80 mg/day oxycodone/aspirin – PA > 4 grams of aspirin/day Daraprim (pyrimethamine) – PA Percocet # (oxycodone/acetaminophen) – PA > 80 mg/day i. Effective March 7, 2016, the following opioid Roxicodone # (oxycodone immediate-release) – dependence agent will require prior authorization for PA > 80 mg/day all doses. Vicoprofen # (hydrocodone 7.5 mg/ibuprofen) – PA > 80 mg/day buprenorphine/naloxone tablet – PA j. Effective March 7, 2016, the following opioid PA – Prior authorization is required. The prescriber analgesic agents will require prior authorization for must obtain prior authorization for the drug in order for all doses. the pharmacy to receive payment. Note: Prior authorization applies to both the brand-name and the Dolophine (methadone oral) – PA FDA “A”-rated generic equivalent of listed product. Methadose (methadone oral) – PA # – This designates a brand-name drug with FDA k. Effective March 7, 2016, the opioid analgesic “A”-rated generic equivalents. Prior authorization is agents will have updated high dose and/or quantity required for the brand, unless a particular form of that limit restrictions as described in Table 8: Opioids drug (for example, tablet, capsule, or liquid) does not and Analgesics as well as the Pain Initiative. As a have an FDA “A”-rated generic equivalent. result, the following listings will change. ̂ – This drug is available through the health care Astramorph-PF (morphine, injection) – PA > 120 professional who administers the drug. MassHealth mg/day does not pay for this drug to be dispensed through a Dilaudid # (hydromorphone) – PA > 32 mg/day retail pharmacy. Duragesic # (fentanyl 12, 25, 50 mcg/hr transdermal system) – PA > 50 mcg/hr and PA > 10 H – This drug is available only in an inpatient hospital patches/month setting. MassHealth does not pay for this drug to be Duragesic (fentanyl 75, 100 mcg/hr transdermal dispensed through the retail pharmacy or physician's system) – PA office.

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