Current information for pharmacists about the MassHealth Pharmacy program
MassHealth Pharmacy Program
Number 72
July 16, 2012
Pharmacy Facts
MassHealth Pharmacy Program
www.mass.gov/masshealth/pharmacy
Editor: Vic Vangel
Contributors: Chris Burke, Gary Gilmore, Paul Jeffrey, James Monahan, Nancy 
Schiff

MHDL Updates 

Below are certain updates to the MassHealth Drug List 
(MHDL). See the MHDL for a complete listing of 
updates. 

1. Additions 
The following newly marketed drugs have been added to 
the MassHealth Drug List as of July 16, 2012. 

Cosopt PF (dorzolamide/timolol, preservative free) 
– PA 
Intermezzo (zolpidem, sublingual tablet) – PA 
Korlym (mifepristone) – PA 
Omontys (peginesatide) ^ – PA 
Picato (ingenol) – PA 
Qnasl (beclomethasone nasal aerosol) – PA 
Revlimid (lenalidomide 2.5 mg) 
– PA > 30 units/month 
Subsys (fentanyl sublingual spray) – PA 
ZIOPTAN (tafluprost) – PA 

2. New FDA “A” –Rated Generics 
The following FDA “A”-rated generic drugs have been 
added to the MassHealth Drug List as of July 16, 2012. 
The brand name is listed with a # symbol, to indicate that 
prior authorization is required for the brand. 

New FDA “A”-Rated Generic Drug 	Generic Equivalent 
clopidogrel 				Plavix # 
lamivudine/zidovudine 			Combivir # 

3. Change in Prior-Authorization Status 
a. The following drug no longer requires prior 
authorization effective July 16, 2012. 
Derma-smoothe FS # (fluocinolone body oil, 
scalp oil) 
hydrocortisone acetate/aloe vera cream, gel, lotion 

b. The prior-authorization requirements for the following 
drug have changed. The new prior-authorization 
requirement is shown below. 
Veramyst (fluticasone furoate nasal spray) – PA = 
4 years and > 1 inhaler/month 

c. The following topical corticosteroids will require prior 
authorization effective July 30, 2012 
Apexicon-E (diflorasone cream/emollient) – PA 
Kenalog (triamcinolone spray) – PA 
Texacort (hydrocortisone solution) – PA 
Topicort (desoximetasone cream, gel, ointment) 

– PA 
Trianex (triamcinolone 0.05% ointment) – PA 

# This is a brand-name drug with FDA “A” -rated generic equivalents. Prior 
authorization is required for the brand, unless a particular form of that drug 
(for example, tablet, capsule, or liquid) does not have an FDA “A” -rated 
generic equivalent. 

d. The following otic antibiotics will require prior authorization effective 
July 30, 2012. 
Coly-Mycin S (colistin/neomycin/thonzonium/ 
hydrocortisone) – PA 
Cortisporin-TC (colistin/neomycin/thonzonium/ 
hydrocortisone) – PA 

e. The following laxatives will require prior authorization 
effective July 30, 2012. 
CoLyte with flavor packs (polyethylene glycol-
electrolyte solution) – PA 
GoLytely packet (polyethylene glycol-electrolyte 
solution) – PA 

f. The following drug is restricted to a health-care 
professional 
ketamine injection ^ – PA 


4. Updated Non-Drug Product List 
The MassHealth Non-Drug Product List has been updated 
to reflect recent changes to the MassHealth Drug List. The 
following non-drug products have been added to the Non-
Drug Product List as covered without prior authorization, 
effective July 16, 2012. 
Hyper-Sal (sodium chloride 3.5% for inhalation) 
Nebusal (sodium chloride 6% for inhalation) 
sodium chloride for inhalation 

5. Corrections 
a. The following drugs have been added to the 
MassHealth Drug List. They were omitted in error. 
These changes do not reflect any change in 
MassHealth policy. 
Busulfex (busulfan injection) 
Desowen # (desonide cream) 
Epivir (lamivudine solution) 
Epivir # (lamivudine tablet) 
Fludara # (fludarabine) 
fluocinolone cream, ointment, solution 
Hycamtin # (topotecan) 
hydrocortisone cream, lotion, ointment 
Myleran (busulfan tablet) 
Olux-E (clobetasol propionate foam/emollient) 
QUADRAMET (samarium SM 153 lexidronam) ^ 
SSD # (silver sulfadiazine) 
Tabloid (thioguanine) 
Vitrasert (ganciclovir intravitreal implant) ^ 


b. The following drugs previously had an “A”-rated 
generic equivalent that is no longer available on the 
market. Prior authorization is no longer required for the 
branded products. 
Grifulvin V (griseofulvin 500 mg tablet) 
Gris-Peg (griseofulvin 125 mg, 250 mg tablet) 

^ This drug is available through the health-care professional who 
administers the drug. MassHealth does not pay for this drug to be 
dispensed through a retail pharmacy. 

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