MHDL Update Additions Change in Prior-Authorization Status

Number 149, June 26, 2020

MHDL Update Change in Prior-Authorization Status Below are certain updates to the MassHealth a. Effective June 29, the following topical Drug List (MHDL). See the MHDL for a antiviral agents will no longer require prior complete listing of updates. authorization. Additions • Xerese (acyclovir/hydrocortisone) • BP Effective June 29, 2020, the following newly Zovirax (acyclovir cream, ointment) marketed drugs have been added to the b. Effective June 29, the following triptan will MassHealth Drug List. no longer require prior authorization when used within established quantity limits. • Ayvakit (avapritinib) – PA • Zomig (zolmitriptan tablet) BP – PA > • Caplyta (lumateperone) – PA 18 units/month • Gvoke (glucagon auto-injection, prefilled c. Effective June 29, the following ophthalmic syringe) – PA anti-inflammatory agents will no longer • Jatenzo (testosterone undecanoate require prior authorization. capsule) – PA • Acuvail (ketorolac 0.45% ophthalmic • Nexletol (bempedoic acid) – PA solution) • Palforzia (peanut allergen powder-dnfp) – • Maxidex (dexamethasone ophthalmic PA suspension) • Procysbi (cysteamine delayed-release • Nevanac (nepafenac 0.1% ophthalmic granule) – PA suspension) • Quzyttir (cetirizine injection) ^ – PA d. Effective June 29, 2020, the following • Recarbrio (imipenem/cilastatin/relebactam) combination H. Pylori medication will no – PA longer require prior authorization. • Reyvow (lasmiditan) – PA • Pylera (bismuth • romidepsin - PA subcitrate/metronidazole/tetracycline) • Ruxience (rituximab-pvvr) – PA e. Effective June 29, 2020, the following • Talicia (omeprazole/amoxicillin/rifabutin) – antiretroviral agent will no longer require PA prior authorization. • Tazverik (tazemetostat) – PA • Symtuza (darunavir/cobicistat/ • Truxima (rituximab-abbs) – PA emtricitabine/tenofovir alafenamide) PD • Ubrelvy (ubrogepant) – PA (continued) • Valtoco (diazepam nasal spray) – PA > 10 units/month

Pharmacy Facts Number 149 Page 2 of 2

Updated MassHealth Brand Name use to help identify MassHealth patients who need food assistance and connect them to Preferred Over Generic Drug List resources in the community. Those food assistance resources can provide your The MassHealth Brand Name Preferred Over patients with immediate access to food, as Generic Drug List has been updated to reflect well as recurring financial support for the recent changes to the MassHealth Drug List. purchase of food. a. Effective June 29, 2020, the following ● Patient-facing food assistance handout, agent will be added to the MassHealth which provides information about available Brand Name Preferred Over Generic Drug resources. The handout can be printed List. and given to patients, or if you are • Kitabis Pak (tobramycin inhalation connecting with patients via phone, text, or BP solution) email, you can provide patients a link for b. Effective June 29, 2020, the following this handout: agent will be removed from the : MassHealth Brand Name Preferred Over o English version Generic Drug List. https://www.mass.gov/doc/food- • Coly-Mycin S (colistin/neomycin/ assistance-during-the-covid-19- thonzonium/hydrocortisone) emergency/download o Spanish version: Legend https://www.mass.gov/doc/asistencia- PA Prior authorization is required. The prescriber must alimentaria-durante-la-emergencia- obtain prior authorization for the drug in order for the por-covid-19/download pharmacy to receive payment. Note: PA applies to You can find accessible versions for both the brand- name and the FDA “A”-rated generic o equivalent of listed product. this handout here (English) and here (Spanish) # Designates 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 ● Provider-facing guide to help you better example, tablet, capsule, or liquid) does not have an understand how to identify patients who

FDA “A”-rated generic equivalent. need food assistance and the resources BP Brand preferred over generic equivalents. In general, available to help them. MassHealth requires a trial of the preferred drug or : clinical rationale for prescribing the nonpreferred drug o English version generic equivalent. https://www.mass.gov/doc/connecting- PD In general, MassHealth requires a trial of the your-patients-with-food- preferred drug (PD) or a clinical rationale for resources/download prescribing a nonpreferred drug within a therapeutic o Spanish version: class. https://www.mass.gov/doc/como- CO Carve-Out. This agent is listed on the Acute Hospital conectar-a-sus-pacientes-con- Carve-Out Drugs List and is subject to additional monitoring and billing requirements recursos-de-alimentos/download o You can find accessible versions for Food Assistance Resources for this guide here (English) and here MassHealth Members (Spanish) We hope that this information will be helpful to your MassHealth patients who need food As a result of the COVID-19 pandemic, a assistance. If you have any questions about growing number of individuals and families these resources, please call the Project Bread across Massachusetts are facing food FoodSource Hotline at 1-800-645-8333. insecurity, many for the first time. MassHealth, in partnership with other state agencies and food non-profit organizations, has developed a simple guide that you can If you have questions or comments, or want to be removed from this fax distribution, please contact Josel Fernandes at (617) 423-9842.