MassHealth Quick Reference Guide
Alpha-1 Adrenergic Blockers
| doxazosin prazosin | terazosin Flomax—PA | Rapaflo—PA Uroxatral—PA |
Angiotensin Converting Enzyme Inhibitors
| benazepril captopril enalapril fosinopril | lisinopril moexipril quinapril ramipril—PA | trandolapril Aceon—PA Altace—PA |
Angiotensin II Receptor Antagonists
| Atacand—PA Avapro—PA Benicar—PA | Cozaar—PA Diovan—PA | Micardis—PA Teveten—PA |
Anticonvulsants
| carbamazepine clonazepam clorazepate diazepam divalproex ethosuximide gabapentin lamotrigine levetiracetam oxcarbazepine | phenobarbital phenytoin primidone topiramate—PA > 18 yrs. valproate valproic acid zonisamide Banzel—PA Celontin | Dilantin Felbatol Gabitril—PA > 18 yrs. Keppra XR—PA Lyrica—PA Mebaral Peganone Stavzor—PA Vimpat tablets—PA |
Antidepressants
| bupropion bupropion SR bupropion XL—PA citalopram fluoxetine 10 mg/20 mg capsules fluoxetine—PA 20 mg tablets and 40 mg capsules MAOIs | maprotiline mirtazapine mirtazapine ODT—PA nefazodone paroxetine paroxetine CR—PA sertraline TCAs trazodone | venlafaxine Aplenzin—PA Cymbalta—PA Effexor XR—PA Lexapro—PA Luvox CR—PA Pexeva—PA Pristiq—PA Wellbutrin XL—PA |
Antidiabetic Agents
| acarbose acetohexamide chlorpropamide glimepiride glipizide glipizide ER glyburide | metformin metformin ER tolazamide tolbutamide Actos Avandia Diabeta—PA | Fortamet—PA Glyset—PA Insulin, Prefilled Syr—PA Januvia—PA Prandin—PA Starlix—PA |
Antihistamines
| brompheniramine cetirizine chlorpheniramine | diphenhydramine fexofenadine—PA loratadine | Clarinex—PA Xyzal—PA |
Antipsychotics
| clozapine risperdone1—Q Abilify1—Q Abilify Discmelt—PA Fazaclo—PA | Geodon1—Q Invega1—Q Risperdal M—PA Risperdal Consta—Q Seroquel1—Q | Seroquel XR1—Q Zyprexa1—Q Zyprexa IM—PA Zyprexa Zydis—PA |
Asthma
| albuterol metaproterenol Advair—PA Aerobid Aerobid-M Alupent—PA Alvesco Atrovent # Azmacort | Brovana—PA Combivent Flovent Foradil—PA Intal # Maxair—PA ProAir HFA Proventil HFA—PA | Pulmicort Qvar Serevent—PA Symbicort—PA Tilade Vanceril Ventolin HFA—PA Xopenex—PA |
Beta Adrenergic Blocking Agents
| acebutolol atenolol betaxolol bisoprolol carvedilol esmolol | labetalol metoprolol nadolol pindolol propranolol propranolol ER | sotalol timolol Bystolic—PA Coreg CR—PA Innopran XL—PA Levatol—PA |
Calcium Channel Blocking Agents
| amlodipine diltiazem felodipine isradipine | nicardipine nifedipine nimodipine | nisoldipine—PA verapamil Dynacirc CR—PA |
H2 Antagonists
| cimetidine famotidine nizatidine—PA | ranitidine ranitidine capsules—PA |
Hypnotics
| estazolam—Q flurazepam—Q temazepam—Q temazepam 22.5 mg—PA | triazolam—Q zaleplon—Q zolpidem—Q Ambien—PA | Ambien CR—PA Doral—PA Edluar—PA Lunesta—PA Restoril 7.5 mg—PA |
PA > 10 units/month for above hypnotics.
Leukotrienes
| Accolate—PA > 16 yrs. | Singulair—PA > 16 yrs. | Zyflo CR—PA |
Narcotic Agonist Analgesics
| fentanyl patch—PA levorphanol—Q methadone—Q | morphine CR—Q morphine SR—PA oxycodone ER—PA | Nucynta—PA Opana—PA |
Proton Pump Inhibitors
| omeprazole 10 mg/20 mg omeprazole 40 mg—PA pantoprazole—PA Aciphex—PA | Kapidex—PA Nexium—PA Prevacid—PA > 2 yrs. | Prilosec—PA Protonix—PA Zegerid—PA |
Statins
| lovastatin—Q pravastatin—Q simvastatin—Q Advicor—PA | Altoprev—PA Crestor—PA Lescol—PA | Lescol XL—PA Lipitor—PA Simcor—PA |
Triptans
| sumatriptan Inj.—Q Amerge—PA Axert—Q Frova—PA | Imitrex Tab—PA Imitrex Nasal—PA Maxalt—PA Relpax—PA | Treximet—PA Zomig—Q Zomig ZMT—PA |
PA > 8 units/month for Axert and Zomig and 8 injs./month for Imitrex inj.
This document does not represent the complete MassHealth Drug List. For more information, please visit the MassHealth Web site at www.mass.gov/druglist.
MassHealth evaluates the prior-authorization status of drugs on an ongoing basis, and updates the MassHealth Drug List accordingly.
1 = PA required for polypharmacy (overlap of more than 60 days).
# This is a brand-name drug with FDA “A”-rated generic equivalents. PA is required for the brand, unless a particular form of that drug does not have an FDA “A”-rated generic equivalent.
PA = Prior authorization required. Prior-authorization forms can be found at www.mass.gov/druglist.
Q = PA is required to exceed certain quantity limits.
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Quick Reference Guide (PDF) download
Last updated 11/09/09
This information is provided by MassHealth.