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

Health Safety Net (HSN) Claims 

As of 10/1/07 the Pharmacy Online Processing 
System (POPS) has accepted claims from Health 
Safety Net (HSN) at in-network pharmacies. This 
program was formerly known as the Uncompensated 
Care Pool. HSN is a fund set up to help pay for health 
services at participating hospitals and community 
health centers for certain individuals. Health Safety 
Net is not a MassHealth coverage type, but 
MassHealth determines an applicant’s eligibility for 
HSN services. Eligible applicants may receive HSN 
services at participating hospitals and community 
health centers only, including hospitals and community 
health centers that are federally designated “340-B” 
entities. If a non-participating pharmacy tries to submit 
a claim for a HSN member it will receive the following 
message: 

40- Contact Health Safety Net Help Desk 
(877-910-2100) for assistance. Claim must be 
processed by HSN-designated provider. 

MHDL Update 

The following newly marketed drugs have been added 
to the MassHealth Drug List. 

Amrix (cyclobenzaprine extended-release) – PA 

AzaSite (azithromycin, ophthalmic) – PA 

Azor (amlodipine/olmesartan) – PA 

CaloMist (cyanocobalamin) – PA 

Centany Kit (mupirocin) – PA 

Divigel (estradiol) 

Elestrin (estradiol) 

Extina (ketoconazole) – PA 

Inova (benzoyl peroxide) – PA 

Isentress (raltegravir) 

Lipofen (fenofibrate) – PA 

Peranex HC (hydrocortisone/lidocaine) – PA 

Perforomist (formoterol) – PA 

Selzentry (maraviroc) – PA 1 

Tamiflu 30 mg (oseltamivir) – PA all quantities (June 
1st to September 30th); PA > 20 capsules/month 
and PA > 40 capsules/season (October 1st to 
May 31st) 

 

Tersi (selenium sulfide) – PA 

Xyralid (hydrocortisone/lidocaine) – PA 

Xyzal (levocetirizine) – PA 

Zytopic (triamcinolone) – PA 

1 The Trofile assay test, which predicts response to Selzentry, requires 
PA. Please use the Selzentry PA Request form and send request to theMassHealth Drug Utilization Review Program. 

Change in PA Status 

The PA requirements for Subutex and Suboxone are 
changing. The following PA requirements are effective 
January 2, 2008. 

Subutex (buprenorphine) – PA 

Suboxone (buprenorphine/naloxone) > 32 mg/day – PA 

Suboxone (buprenorphine/naloxone) > 24 and < 32 mg/day 
– PA is required after 90 days duration of therapy 

Suboxone (buprenorphine/naloxone) > 16 and < 24 mg/day 
– PA is required after 180 days duration of therapy 

Suboxone (buprenorphine/naloxone) < 16 mg/day – PA is 
required after 365 days duration of therapy 

The PA requirements for ocular antibiotics are changing. 
The following PA requirements are effective January 2, 
2008. 

Ciloxan Ointment (ciprofloxacin, ophthalmic ointment) – PA 

Iquix (levofloxacin, ophthalmic) – PA 

Quixin (levofloxacin, ophthalmic) – PA 
Tobrex Ointment (tobramycin, ophthalmic ointment) – PA 

Vigamox (moxifloxacin, ophthalmic) – PA 

Zymar (gatifloxacin, ophthalmic) – PA 

The following PA requirements are effective January 2, 
2008. 

Restasis (cyclosporine, ophthalmic) – PA > 64 units/month 

The PA requirements for the following Triptans are 
changing. Please refer to Table 14 for the complete list of 
prior authorization requirements for the Triptans. 

Axert (almotriptan) – PA > 8 units/month 

Imitrex (sumatriptan), injection – PA > 4 units (8 
injections/month) 

Zomig (zolmitriptan) – PA > 8 units/month 

The following drug requires PA. 

Acthar (corticotropin) – PA 



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

www.mass.gov/masshealth/pharmacy 

Number 32 

December 13, 2007