Number 168 June 23, 2021

MHDL Update · sotrovimab (COVID EUA – May 26, 2021) Below are certain updates to the MassHealth Drug List (MHDL). See the MHDL for a complete Change in Prior-Authorization Status listing of updates. a. Effective June 28, 2021, the following dermatologic agents will no longer require Additions prior authorization (PA). a. Effective June 28, 2021, the following newly marketed drugs have been added to the · Aldara # (imiquimod 5% cream) MassHealth Drug List. · Condylox Gel (podofilox gel) · Breyanzi (lisocabtagene maraleucel) CO ^ · Efudex (fluorouracil 5% cream) BP – PA b. Effective June 28, 2021, the following · Eysuvis (loteprednol 0.25% suspension) antipsychotic agents will no longer require – PA PA within updated quantity limits. Pediatric · fluorescein/benoxinate Behavioral Health Medication Initiative · Gemtesa (vibegron) – PA criteria will still apply. For additional · Herceptin Hylecta information, please see the Pediatric (trastuzumab/hyaluronidase-oysk) – PA Behavioral Health Medication Initiative · Herzuma (trastuzumab-pkrb) – PA documents found at www.mass.gov/druglist. · Kanjinti (trastuzumab-anns) – PA · Abilify # (aripiprazole tablet) – PA < 6 · Lupkynis (voclosporin) – PA years and PA > 2 units/day · Margenza (margetuximab-cmkb) – PA · Seroquel XR # (quetiapine extended- · Mvasi (bevacizumab-awwb) – PA release 150 mg, 200 mg) – PA < 6 years · Mycapssa (octreotide capsule) – PA and PA > 2 units/day · Zyprexa # (olanzapine 2.5 mg, 5 mg, 7.5 · Ogivri (trastuzumab-dkst) – PA mg, 10 mg, 20 mg tablets) – PA < 6 · Olinvyk (oliceridine) ^ – PA years and PA > 2 units/day · Ontruzant (trastuzumab-dttb) – PA c. Effective June 28, 2021, the following · Orgovyx (relugolix) – PA antipsychotic agent will no longer require · Oxlumo (lumasiran) – PA PA when used within quantity limits. · Ponvory (ponesimod) – PA Pediatric Behavioral Health Medication · Qelbree (viloxazine) – PA Initiative criteria will still apply. For · Tepmetko (tepotinib) – PA additional information, please see the · Thyquidity (levothyroxine) Pediatric Behavioral Health Medication · Trazimera (trastuzumab-qyyp) – PA Initiative documents found at · Verquvo (vericiguat) – PA www.mass.gov/druglist. · Zirabev (bevacizumab-bvzr) – PA · Risperdal M-Tab # (risperidone 0.25 mg b. Effective for the date listed below, the orally disintegrating tablet) – PA < 6 following COVID-19 preventative therapy has years and PA > 2 units/day been added to the MassHealth Drug List on d. Effective June 28, 2021, the following June 09, 2021. antipsychotic agent will require PA when Pharmacy Facts, Number 168 Page 2 of 3

exceeding newly established quantity · Cabenuva (cabotegravir/rilpivirine) PD limits. Pediatric Behavioral Health Medication Initiative criteria will still Updated MassHealth Brand Name apply. For additional information, please Preferred Over Generic Drug List see the Pediatric Behavioral Health Medication Initiative documents found at The MassHealth Brand Name Preferred Over www.mass.gov/druglist. Generic Drug List has been updated to reflect · Risperdal M-Tab # (risperidone 2 mg recent changes to the MassHealth Drug List. orally disintegrating tablet) – PA < 6 a. Effective June 28, 2021, the following agents years and PA > 2 units/day will be added to the MassHealth Brand e. Effective June 28, 2021, the following Name Preferred Over Generic Drug List. antipsychotic agent will require PA for all · Bepreve (bepotastine) BP ages. · Combigan (brimonidine/timolol, · Risperdal M-Tab (risperidone 3 mg ophthalmic) BP orally disintegrating tablet) – PA · Prezista (darunavir) BP PD f. Effective June 28, 2021, the following · Revlimid (lenalidomide) BP – PA anticonvulsant agent will require PA · Teflaro (ceftaroline) BP – PA when exceeding newly established · Thiola (tiopronin) BP dosing limits. Pediatric Behavioral Health · Zoladex (goserelin) BP – PA Medication Initiative criteria will still b. Effective June 28, 2021, the following agents apply. For additional information, please will be removed from the MassHealth Brand see the Pediatric Behavioral Health Name Preferred Over Generic Drug List. Medication Initiative documents found at · Atripla # www.mass.gov/druglist. (efavirenz/emtricitabine/tenofovir) · Neurontin # (gabapentin capsule, · Kaletra # (lopinavir/ritonavir) solution, tablet) – PA < 6 years and · Purixan (mercaptopurine oral suspension) PA > 3600 mg/day – PA g. Effective June 28, 2021, the following · Rapaflo (silodosin) – PA injectable antibiotic agents will no longer · Silenor (doxepin tablet) – PA require PA. · Truvada # (emtricitabine/tenofovir · Cubicin # (daptomycin) disoproxil fumarate) · daptomycin Legend h. Effective June 28, 2021, the following glaucoma agent will no longer require PA Prior authorization is required. The prescriber must obtain prior authorization for the drug in order for the PA. pharmacy to receive payment. Note: PA applies to both · Azopt (brinzolamide) BP the brand-name and the FDA “A”-rated generic i. Effective June 28, 2021, the following equivalent of listed product. hereditary angioedema agent will require # Designates a brand-name drug with FDA “A”-rated PA. generic equivalents. Prior authorization is required for · Kalbitor (ecallantide) ^ – PA the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an j. Effective June 28, 2021, the following FDA “A”-rated generic equivalent. oncology agent will require PA. BP · Herceptin (trastuzumab) – PA Brand preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or k. Effective July 1, 2021, the following clinical rationale for prescribing the nonpreferred drug antiretroviral/HIV agent will no longer generic equivalent. require PA. Please direct any questions or comments (or to be removed from this fax distribution) to [email protected] Pharmacy Facts, Number 168 Page 3 of 3

PD In general, MassHealth requires a trial of the preferred does not pay for this drug to be dispensed through a drug (PD) or a clinical rationale for prescribing a retail pharmacy. nonpreferred drug within a therapeutic class. CO Carve-Out. This agent is listed on the Acute ^ This drug is available through the health care Hospital Carve-Out Drugs List and is subject to professional who administers the drug. MassHealth additional monitoring and billing requirements.

Please direct any questions or comments (or to be removed from this fax distribution) to [email protected]