Number 45 

October 3, 2008

www.mass.gov/masshealth/pharmacy

• Editor: Vic Vangel • Contributors: Chris Burke, Gary Gilmore, 
Paul Jeffrey, James Monahan, Chuck Young, Nancy Schiff • 

MHDL Update 

1. Additions 

The following newly marketed drugs have been added to the 
MassHealth Drug List effective 10/15/2008. 

Cimzia (certolizumab) – PA 
Hypertet (tetanus immune globulin IM, human) 
Kinrix (diphtheria/tetanus toxoids/acellular pertussis/ 

 poliovirus, inactivated vaccine) 1 
Liquadd (dextroamphetamine) – PA > 450 ml/month 
Patanase (olopatadine) – PA 
Pentacel (diphtheria/tetanus toxoids/acellular 

 pertussis/poliovirus, inactivated/haemophilus b 

 conjugate vaccine) 1 

Relistor (methylnaltrexone) – PA 
Requip XL (ropinirole extended-release) – PA 
Rotarix (rotavirus vaccine) 1 
Stavzor (valproic acid) – PA 
Treximet (sumatriptan/naproxen) – PA 
Zervalx (L-methylfolate) – PA 
Zingo (lidocaine, intradermal injection) – PA 

1 Product may be obtained through the Massachusetts Department 
of Public Health (DPH). Please check with DPH for availability. 
MassHealth does not pay for immunizing biologicals (i.e., 
vaccines) and tubercular (TB) drugs that are available free of 
charge through local boards of public health or through DPH 
without prior authorization (130 CMR 406.413(C)). 

2. New FDA “A”-Rated Generics 

The following FDA “A”-rated generic drugs have been added 
to the MassHealth Drug List. The brand name is listed with 
a # symbol, to indicate that PA is required for the brand. 

New FDA “A”-Rated 

Generic Drug Generic Equivalent 

acarbose Precose # 
divalproex Depakote # 
risperidone tablet – PA Risperdal # tablet – PA 

 > 60 units/month > 60 units/month 

ropinirole Requip # 
zaleplon – PA Sonata # – PA 

 > 10 units/month > 10 units/month 

3. Change in PA Status 

a. The PA requirement for Kadian (morphine sustained 
release) is changing. The following PA requirement is 
effective November 3, 2008. Please see Table 8 for a 
complete list of PA requirements for Narcotic Agonist 
Analgesics. 

Kadian (morphine sustained release) – PA 

b. The PA requirement for Astelin (azelastine) is changing. 
The following PA requirement is effective November 3, 
2008. Please see Table 12 for a complete list of PA 
requirements for antihistamines. 

Astelin (azelastine) – PA 

c. The following oral anti-infectives will require prior 
authorization effective November 3, 2008. Please see 
Table 35 for a complete list of PA requirements for the 
oral anti-infectives. 

Augmentin XR (amoxicillin/clavulante extended- 

 release) – PA 
cefaclor extended-release – PA 
cefadroxil 1 gram tablet – PA 
clarithromycin extended-release – PA 
Ketek (telithromycin) – PA 

d. The following drugs will require prior authorization 
effective November 3, 2008. 

Lamictal Starter Kit (lamotrigine) – PA 
Regranex (becaplermin) – PA > 1 tube/month 

 and > 3 tubes/lifetime 
VFend (voriconazole), suspension, tablet – PA 

e. The following drugs no longer require prior authorization. 

Emend Tri-fold (aprepitant) 
Revlimid (lenalidomide) 

4. Deletions 

The following drugs have been deleted from the MassHealth 
Drug List. MassHealth does not pay for drug products 
(including identical, similar, or related drug products) 
that the U.S. Food and Drug Administration has proposed, 
in a Notice of Opportunity for Hearing (NOOH), to withdraw 
from the market because they lack substantial evidence of 
effectiveness for all labeled indications. 

choline salicylate/magnesium salicylate 
Tricosal (choline salicylate/magnesium salicylate) 
Trilisate (choline salicylate/magnesium salicylate) 

5. Corrections 

The following ingredients have been added to the 
MassHealth Nonlegend (Over-the-Counter) Drug List. 
MassHealth covers these agents when they are used as a 
part of a compounded prescription preparation. They were 
omitted in error. 

cherry syrup 
Ora-Plus suspending vehicle 
Ora-Sweet-SF syrup 
Ora-Sweet oral syrup 
simple syrup 



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