MassHealth Pharmacy Program
Current information for pharmacists about the MassHealth Pharmacy Program
Number 19
April 13, 2006
Pharmacy Facts
MassHealth Pharmacy Program 
• Editor: Vic Vangel • Contributors: Chris Burke, Gary Gilmore, Paul Jeffrey, James Monahan •

MassHealth Drug List Changes in Prior 
Authorization Status
MassHealth has changed the prior-authorization 
requirements for the following medications effective April 17, 2006. 
Adoxa (doxycycline) – PA
Relenza (zanamivir) – PA all quantities (June 1st to 
September 30th); PA > 20 inhalations/month 
and 40 inhalations/season (October 1st to May 31st)
Tamiflu (oseltamivir) – PA all quantities (June 1st to 
September 30th); PA > 10 capsules or 75 ml 
per month and PA > 20 capsules or 150 ml per 
season (October 1st to May 31st)
Zofran ODT (ondansetron, orally disintegrating tablet) – PA
MassHealth has changed the PA requirements of certain 
cerebral stimulants effective April 17, 2006.  The 
following long-acting medications require prior 
authorization for quantities greater than 60 units/month 
separately or in combination with the cerebral stimulants 
listed here.
Adderall XR (amphetamine salts extended-release) – 
PA > 60 units per month
Concerta (methylphenidate extended-release) – PA > 
60 units per month
Focalin XR (dexmethylphenidate extended-release ) – 
PA > 60 units per month
Metadate CD (methylphenidate extended-release) – 
PA > 60 units per month
Ritalin LA (methylphenidate extended-release) – PA > 
60 units per month
The following short-acting and intermediate-acting 
medications require prior authorization for quantities 
greater than 90 units/month, whether used individually or 
in combination with the cerebral stimulants listed here.


Adderall # (amphetamine salts) – PA > 90 units per month
Dexedrine # (dextroamphetamine) – PA > 90 units per month
Focalin (dexmethylphenidate) – PA > 90 units per month
Metadate ER # (methylphenidate extended-release) – 
PA > 90 units per month
Methylin (methylphenidate) – PA > 90 units per month
Ritalin # (methylphenidate) – PA > 90 units per month
Ritalin SR # (methylphenidate extended-release) – 
PA > 90 units per month
Written Prescription Requirements
Prescriptions for over-the-counter drugs require a valid 
prescription, which is not necessarily a written 
prescription.  A valid prescription may be written, oral, 
facsimile, or electronic as permitted by state and federal 
laws.  When filling a prescription for a brand-name 
product when a generic equivalent is available, a written 
prescription is required.  On the face of the prescription, 
in the prescriber’s own handwriting, the words "brand 
name medically necessary" under the words "no 
substitution" must be written out in full and may not be 
abbreviated.

Medicare Part D Prescription Drug Coverage Update
A reminder that MassHealth will provide limited 
assistance for Part D drugs for dual eligible members 
when a Part D plan will not cover the medication at the 
time the prescription is presented.  These procedures 
were summarized in Pharmacy Facts #17 and #18.  If a 
Part D plan denies a claim because the drug is not 
available on the plan’s formulary or due to the plan's prior 
authorization, submit the claim to MassHealth using 
Other Coverage Code 3, along with the appropriate reject 
code.  These reject codes include Reject Codes 70 and 
75.  The claim will still be subject to all of MassHealth’s 
other billing procedures and requirements, with the 
exception of prior authorization.

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