Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111
www.mass.gov/dma	
	MassHealth
	All Provider Bulletin 115
	July 2002

	TO:	All Providers Participating in MassHealth

	FROM:	Wendy E. Warring, Commissioner

	RE:	MassHealth Drug List

Audience	This bulletin contains important information about pharmacy services for MassHealth members.  This information is important for prescribers, pharmacies, community health centers, outpatient hospitals, and nursing facilities.  This information does not apply directly to other providers, including inpatient hospitals, but it is given for your information.

MassHealth 	Effective for prescriptions written on or after August 1, 2002, the Division 
Drug List 	will begin using a new communication tool, the MassHealth Drug List, to specify which drugs need prior authorization when prescribed for MassHealth members.  

The MassHealth Drug List is an alphabetical list of commonly prescribed drugs.  Certain drugs have been grouped into their therapeutic classes.  The MassHealth Drug List provides cross-references to their respective therapeutic class tables, which provide additional clinical information. The prior-authorization requirements specified in the MassHealth Drug List reflect the Division’s prior-authorization policy generally described in the pharmacy regulations and previous provider bulletins, as well as the Division’s and the Drug Utilization Review (DUR) Board’s review of certain gastrointestinal drugs.  The list also specifies the generic over-the-counter drugs that are payable under MassHealth. Any drug that does not appear on the list also requires prior authorization.

The Division and the DUR Board determined whether or not to require prior authorization on the basis of the drugs’ safety and effectiveness.  Cost was a consideration only if two or more drugs were considered to be equally safe and effective.  In that case, the more expensive drug or drugs require prior authorization.  

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Drug List on 	The Division will update the MassHealth Drug List monthly, as needed, 
the DMA 	and will post the updated list on its Web site on the first business day of 
Web Site 	each month prior to the effective date of the change.  The Division will not send a bulletin each month in which there are changes to the list.  However, the Division will provide a summary page on the Web site when the list is updated, and will send e‑mail alerts to those who sign up for them. (See page 6 of this bulletin for more information about e-mail alerts.)  To view, print, or download the most up-to-date version of the Drug List, go to the Division’s Web site at:

www.mass.gov/dma

Pictured above is the home page of the Division’s Web site.  Click the word Pharmacy to get to the Pharmacy page, then click “MassHealth Drug List.”

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Prior 			Prior-authorization requirements for specific drugs are indicated on the
Authorization		MassHealth Drug List beside each listed drug that requires it.  Brand- 
for Drugs 	name drugs that have an FDA “A”-rated generic equivalent require prior authorization and are identified by a number symbol (#) beside the name of the drug.  The generic versions of such drugs are payable under MassHealth without prior authorization.   

Note to pharmacists:  Numerous products that you may dispense as generics will appear as brand-name products on the MassHealth Drug List.  This is because the Division uses the “Orange Book” as the source document for determining brand-generic equivalency.  

Pharmacists can use the override codes in their pharmacy program software to indicate that they are selecting a brand-name product as their generic equivalent.  In doing so, the pharmacy will be paid at the generic rate.

Although the Division will not pay for drugs without prior authorization if they require it, any remaining refills will be paid on an otherwise valid prescription written before any new prior-authorization requirement for the drug goes into effect.
 
Note to nursing facilities:  Although doctors’ orders in a nursing facility are usually reviewed every 30-60 days, prescriptions at the pharmacy can be valid for up to a year.  The pharmacist will know the duration of the prescription.

Members with 	MassHealth is the payer of last resort.  When the member’s primary 
Other Health 	carrier has a preferred drug list, the prescriber must follow the rules of the 
Insurance 	primary carrier first.  The provider may bill the Division for the primary insurer’s copayment without MassHealth prior authorization, except in cases where the drug is subject to a pharmacy service limitation pursuant to 130 CMR 406.413(B) through (E)(4) and (E)(6) through (E)(11).  In such cases, the prescriber must obtain MassHealth prior authorization in order for the pharmacy to bill the Division for the copayment.  These service limitations are also described in various prescriber regulations at 130 CMR 433.443 (physician regulations); 130 CMR 420.418 (dental regulations); 130 CMR 424.419 (podiatrist regulations); 130 CMR 410.463 (outpatient hospital regulations).  These regulations are available on the Division’s Web site.    

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Members Enrolled 	MassHealth members enrolled in a MassHealth-contracted managed care 
in Certain Health 	organization (currently Neighborhood Health Plan, BMC HealthNet Plan, 
Plans  	Network Health, or Fallon Community Health Plan), who receive drug benefits through their health plan, are subject to the rules of that health plan.

New Prior 	In addition to the Division’s preexisting prior-authorization requirements
Authorization	for drugs, the MassHealth Drug List contains new prior-authorization
Requirements	requirements for certain gastrointestinal drugs.  Any remaining refills will 
Effective	be paid on an otherwise valid prescription for one of these gastrointestinal
August 1, 2002	drugs that is written before August 1, 2002.  

Please see the Gastrointestinal Drugs Therapeutic Class Table attached to this bulletin.  This table, in addition to other therapeutic class tables, is part of the MassHealth Drug List, and is available on the Division’s Web site.

The Division and the DUR Board have determined that, in general, agents within each of these classes of gastrointestinal drugs are comparable in safety and effectiveness, but not comparable in terms of cost.

	H2 Antagonists
	Effective for prescriptions written on or after August 1, 2002, Axid (nizatadine), which does not have a generic equivalent, will require prior authorization.  Generic famotidine, ranitidine, and cimetidine will not require prior authorization.  Prescribers are encouraged to consider switching their MassHealth patients who are taking Axid to a generic H2 antagonist, if clinically appropriate.
	
		Proton Pump Inhibitors (PPIs) 
	Effective for prescriptions written on or after August 1, 2002, all PPIs 
	except Protonix (and Prevacid and Prilosec with certain exceptions) will
	require prior authorization.  Prescribers are encouraged to consider
	switching their MassHealth patients who are using PPIs to Protonix, if
	clinically appropriate.  

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Upcoming	The Division and the DUR Board will continue to review new drugs
Therapeutic Class	and additional classes of drugs in the coming months, and will 
Prior Authorization 	post on the Division’s Web site a schedule of new prior-
Changes 	authorization requirements based on these reviews.  The schedule will be available on the Web site approximately one month before a new requirement goes into effect.  The following table shows some upcoming changes to the MassHealth Drug List based on the Division’s and DUR Board’s review of therapeutic classes.

Therapeutic Class	Posted on 
Web	Effective 
Date	
Nonsteroidal anti-inflammatory Drugs	08/01/02	09/01/02	
Antihistamines	09/03/02	10/01/02	

Prior Authorization	Effective August 1, 2002, the Division has three forms that may be used 
Forms 	for requesting prior authorization for drugs.  The forms are designed to maximize the efficiency of the prior-authorization process by eliciting pertinent information from the prescriber.

•	To request prior authorization for a PPI, the prescriber should complete and submit the Proton Pump Inhibitor Prior Authorization Request form.  
•	To request prior authorization for a brand-name drug for which an FDA “A”-rated generic is available, the prescriber should complete and submit the Brand-Name Drug Prior Authorization Request form.
•	To request prior authorization for any other drug, the prescriber should complete and submit the Drug Prior Authorization Request form.

Providers can download the above prior-authorization forms from the Division’s Web site, or may send a written request to the following address or fax number for a supply of any of these forms.  

MassHealth Forms Distribution
P.O. Box 9101
Somerville, MA  02145
Fax:  703-917-4937

When requesting forms from this address, providers must include their provider number, street address (no post-office boxes), a contact name, the exact name of the form (as indicated in bold above), and the quantity desired.

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Prior Authorization	The Division plans to develop more drug and drug-class specific prior-
Forms			authorization forms over time to guide prescribers in providing the 
(cont.)	specific information needed for the DUR Program to review a request for a specific drug.  Prescribers should check the Web site frequently, or sign up for e-mail alerts as described below, to receive notice of updates to the MassHealth Drug List and the availability of new prior-authorization forms.  

E-mail Alerts	Since the MassHealth Drug List will change as often as monthly, you can 
	sign up for e-mail alerts that will inform you when the MassHealth Drug List has been updated on the Web site.  If there are changes to the list from the previous month, they will be summarized on our Web site and will also be integrated into the list upon the effective date.  You will also be able to print the Drug List from the Division’s Web site or save a copy of it to your computer.  

Requesting a	You can get a paper copy of an updated list by submitting a request to:
Paper Copy of
the Drug List 			MassHealth Publications
P.O. Box 9101
Somerville, MA  02145
Fax:  617-576-4487

Include your MassHealth provider number, address, and a contact name with your request.  MassHealth Publications will send you the latest version of the list.  You will need to submit another written request each time you want a paper copy. 

Members may obtain a paper copy from the MassHealth Customer Service Center at 1‑800‑841-2900 (TTY:  1‑800‑497-4648 for the deaf and hard of hearing).

Questions or 	If you have questions or comments about the MassHealth Drug List, call 
Comments 	the Drug Utilization Review Program at 1-800-745-7318, or send an e‑mail to masshealthdruglist@nt.dma.state.ma.us.  The Division will not answer e-mail inquiries directly, but will use these inquiries to develop a frequently asked questions section about the MassHealth Drug List for the Division’s Web site.  

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Questions or		When e-mailing a question or comment to the above e-mail address, 
Comments		please include your name, title, phone number, and fax number. This 
(cont.)	electronic mailbox should be used only for submitting questions or  comments about the MassHealth Drug List. You will receive an automated response message that acknowledges receipt of your e-mail.  If you do not receive an automated reply, please resubmit your inquiry.

MassHealth	If a member has any questions about the MassHealth Drug List, 
Customer Service 	please refer the member to the MassHealth Customer Service Center
Center for		at 1‑800‑841-2900 (TTY:  1‑800‑497-4648 for the deaf and hard of 
Members		hearing).

Attachment to All Provider Bulletin 115, July 2002

Gastrointestinal Drugs – Histamine H2 Antagonists/
Proton Pump Inhibitors
H2 Antagonists
Drug Name†	PA Status	Clinical Notes	
Axid  (nizatidine)	PA	Optimize dosing regimen:
•	For duodenal or gastric ulcer treatment, administer total daily dose between evening meal and bedtime – ulcer healing is directly proportional to degree of nocturnal acid reduction

Duration of therapy:  
•	duodenal ulcer (DU) – 4 weeks 
•	gastric ulcer (GU) – 8 weeks	
Pepcid # (famotidine *)			
Tagamet # (cimetidine *) 			
Zantac # (ranitidine *)			
Proton Pump Inhibitors (PPIs)
Drug Name†	PA Status	Clinicial Notes	
Aciphex (rabeprazole)	PA	Optimize dosing regimen:
•	For maximum efficacy, a PPI must be taken in a fasting state, just before or with breakfast. In general, for patients on PPIs it is not necessary to prescribe other antisecretory agents (e.g., H2 antagonists, prostaglandins).  If an antisecretory agent is prescribed with a PPI, the PPI should not be taken within 6 hours of the H2 antagonist or prostaglandin.  PPIs should not be taken on an “as needed” basis.
QD dosing versus BID dosing:
•	QD dosing is adequate for most individuals except for H.pylori treatment (PPI is BID for 1st two weeks of therapy).  For pathological hypersecretory conditions, such as ZE Syndrome, a BID PPI regimen may be needed for high total daily doses.  When/if a second dose is prescribed, it should be given just before the evening meal.
Apparent PPI non-responder:
•	Careful history should be obtained to ensure appropriate timing of drug administration and no significant drug interactions (see above), before prescribing a second dose or switching to another PPI
 Duration of therapy:  
•	duodenal ulcer (DU) – 4 weeks (QD dosing) 
•	gastric ulcer (GU) – 8 weeks (QD dosing)
•	H. pylori – 2 weeks (BID dosing) + 2 more weeks if DU using QD dosing and 6 more weeks if GU using QD dosing
•	acute symptomatic GERD – 4-8 weeks (QD dosing)	
Nexium (esomeprazole)	PA		
Prevacid (lansoprazole)	PA > 16 years (except suspension for LTC members)		
Prilosec (omeprazole)	PA > 16 years		
Protonix (pantoprazole)			
			
† Brand-name products are capitalized.  Generic products are in lowercase.
# Prior authorization is required for the brand.  An FDA “A”-rated generic is available without prior authorization.
* The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization.