Getting Ready for RSV Season

The recommended palivizumab (Synagis) dosing regimen is  15 mg/kg body weight, given once a month during the respiratory syncytial virus (RSV) season. MassHealth DUR calculates the amount of drug needed for the season at the time of the initial approval for the medication. If the child’s growth is significant, the provider will need to submit documentation of the new weight so that the total number of approved vials may be reviewed for appropriateness.

In Massachusetts, 5 monthly doses will typically provide protection for infants and children when the risk of RSV hospitalization is greatest. Generally, use is confined to the RSV season (October 27, 2008, to March 31, 2009). MassHealth DUR monitors RSV activity in the state and considers extra doses on a case-by-case basis secondary to reports of increased RSV activity.
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The American Academy of Pediatrics Recommends RSV Prophylaxis in the Following Situations:
•	bronchopulmonary dysplasia (BPD) or chronic lung disease (CLD) (excluding asthma or reactive airway disease): Age < 24 months at start of RSV season plus required medication or oxygen supplementation for CLD or BPD within last 6 months;
•	congenital heart disease (CHD): Age < 24 months at the start of RSV season plus hemodynamically significant CHD;
•	gestational age < 28 weeks and current age < 12 months old at the start of RSV season;
•	gestational age 29-32 weeks and current age < 6 months old at the start of RSV season; or
•	gestational age 32-35 weeks and current age < 6 months old at the start of RSV season plus ≥ 2 risk factors (daycare attendance, school aged siblings, exposure to environmental air pollutants, congenital airway abnormalities, and/or severe neuromuscular disease).

Methods to Decrease Risk of RSV Infection 
•	Avoid passive smoking due to effects on respiratory health.
•	Encourage breastfeeding due to increased immunity.
•	Sanitize hands to prevent nosocomial spread.	What’s New with the Flu

Due to widespread resistance, amantadine and rimantadine are no longer recommended for the treatment or chemoprophylaxis of influenza A in the United States. Instead, neuraminidase inhibitors should be considered.

For the 2008-2009 influenza season, the Centers for Disease Control (CDC) has stated that the resistance rate to oseltamivir continues to remain below 5%, and therefore continues to recommend it along with zanamivir as second-line agents for treatment and prophylaxis of seasonal influenza in the United States.

PA is required for all neuraminidase inhibitor requests from June 1 to September 30. However, from October 1 to May 1 of each year PA is required only when the following quantity limits are exceeded:
•	oseltamivir 30 mg capsules >20 units/month or 40 units/season
•	oseltamivir 45 mg or 75 mg capsules >10 units/month or 20 units/season
•	oseltamivir suspension >75 ml/month or 150 ml/season
•	zanamivir >20 inhalations/month or 40 inhalations/season

PA is required for the live, attenuated influenza vaccine (LAIV) Flumist. It is now FDA-approved for children as young as 2 years of age.
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Selected Updates from the 2008-2009 Influenza Prevention & Control Recommendations
•	Beginning with the 2008-2009 season, annual vaccination of all children aged 5-18 years is recommended
•	Children 6 months to 8 years of age should initially receive 2 doses of trivalent inactivated influenza vaccine (TIV) or live attenuated influenza vaccine (LAIV), (depending on age) and administered ≥4 weeks apart
•	Children 6 months to 8 years of age receiving only 1 dose of the influenza vaccine in their first year of vaccination should receive 2 more doses in just the immediate following year
•	For 2008-2009 the influenza vaccine will contain three new influenza virus strains. A/Brisbane/59/2007(H1N1)-like virus, A/Brisbane/10/2007 (H3N2)-like virus, and B/Florida/4/2006-like virus.	

November 2008, Volume 1, Issue 5

The Prescriber E-Letter is a quarterly update designed to enhance the transparency and efficiency of the MassHealth 
drug prior authorization (PA) process and the MassHealth Drug List. Each issue will highlight key clinical
 information and updates to the MassHealth Drug List. The Prescriber E-Letter was prepared by the 
MassHealth Drug Utilization Review Program and the MassHealth Pharmacy Program.

Recent MassHealth Drug List Updates

November 2008

Volume 1, Issue 5

Drug/Drug Class	Addition/Deletion/Change	Rationale	
Oral anti-infectives
	Change in PA status; requires PA

amoxicillin/clavulanate extended-release (Augmentin XR) 
clarithromycin extended-release (BiaxinXL#)
cefaclor extended-release 	There are more cost-effective alternatives available for the management of the same clinical conditions. Augmentin XR, clarithromycin extended-release, and cefaclor extended-release are available as generic immediate release formulations. The generic immediate release formulations are available without prior authorization.	
Vaccines	Addition; does not require PA

diphtheria/tetanus toxoids/acellular pertussis/poliovirus, inactivated vaccine (Kinrix)

diphtheria/tetanus toxoids/acellular pertussis/poliovirus, inactivated/haemophilus b conjugate vaccine (Pentacel)  	Combination vaccines are comparably priced to single entity vaccines and allow for fewer injections. 

In addition, the Department of Public Health has released a statement encouraging use of Pentacel due to a shortage of the 3-dose Hib vaccine.

Some vaccine products may be obtained through the Massachusetts Department of Public Health (DPH). 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.   	
aprepitant       (Emend Tri-fold)	Change in PA status; does not require PA
	Aprepitant is indicated for use in a specific patient population. Due to findings from a recent quality assurance analysis, the PA
requirement has been removed.	
azelastine  (Astelin)  	Change in PA status; requires a PA
	There are more cost-effective oral alternatives available for the management of the same clinical condition including cetirizine and loratadine.	
becaplermin (Regranex) 	Change in PA status; requires PA if quantity exceeds 1 tube/month or  3 tubes/lifetime	Due to the addition of a black box warning that indicates an increased risk of cancer-related mortality in patients who use greater than 3 tubes per lifetime, prior authorization will be required. 	
cefadroxil 1 gram tablet	Change in PA status; requires PA
	There are more cost-effective alternatives available for the management of the same clinical conditions. Cefadroxil 500 mg is available without prior authorization.	
certolizumab (Cimzia)	Addition; requires PA	MassHealth requires prior authorization for all TNF-blocking agents. Conventional oral therapies are often used as first line therapies for the same indications and many of these agents do not require PA. 	
choline salicylate/magnesium salicylate
(Tricosal)
(Trilisate)	Deletion; no longer on 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.	
dextroamphetamine (Liquadd)	Addition; requires PA for quantities greater than 450 ml/month	MassHealth has quantity limits in place for all CNS stimulants in order to promote appropriate use. 	

Recent MassHealth Drug List Updates are continued on next page.

Drug/Drug Class	Addition/Deletion/Change	Rationale	
human respiratory syncytial virus immune globulin (RespiGam)	Deletion; no longer on MassHealth Drug List
	This product has been removed from the MassHealth Drug List because it has been discontinued by the manufacturer.	
Human tetanus immune globulin (Hypertet)	Addition; does not require PA	Human tetanus immune globulin is indicated for the prophylaxis and treatment of tetanus.	
lamotrigine (Lamictal Starter Kit)  	Change in PA status; requires PA
	Generic lamotrigine was recently FDA approved and does not require prior authorization. Therefore brand-name Lamictal requires prior authorization.	
lenalidomide (Revlimid)	Change in PA status; does not require PA	Lenalidomide is indicated for use in a specific patient population. Due to findings from a recent quality assurance analysis, the PA
requirement has been removed.	
lidocaine
intradermal injection
(Zingo)	Addition; requires PA	There are more cost-effective alternatives available for management of the same clinical condition including topical lidocaine.	
l-methylfolate
(Zervalx)	Addition; requires PA	MassHealth has determined that medical foods should require prior authorization due to the less-than-rigorous standards for evaluating their efficacy when compared to medications. Furthermore, medical foods do not require FDA approval to be marketed.	
methylnaltrexone                 (Relistor)	Addition; requires PA	There are more cost-effective alternatives available for management of the same clinical conditions including stimulant, saline, and osmotic laxatives. Additionally, there is no evidence available to support the use of one agent over another.	
morphine sustained release             (Kadian)	Change in PA status; requires a PA
	There are more cost-effective alternatives available for the management of the same clinical conditions. Generic long-acting morphine is available without prior authorization when less than 360 mg/day is used. 	
olopatadine (Patanase)	Addition; requires PA	There are more cost-effective oral alternatives available for the management of the same clinical conditions including cetirizine and loratadine.	
ropinirole extended-release             (Requip XL)	Addition; requires PA	There are more cost-effective alternatives available for the management of the same clinical conditions including generic immediate-release ropinirole.	
rotavirus vaccine (Rotarix) 	Addition; does not require PA	Rotavirus vaccine is indicated for the prevention of rotavirus gastroenteritis caused by G1 and non-G1 types (G3, G4, and G9).	
rotigotine   
(Neupro)	Deletion; no longer on MassHealth Drug List	This product has been removed from the MassHealth Drug List because it has been discontinued by the manufacturer.	
somatrem  (Protropin)	Deletion; no longer on MassHealth Drug List	This product has been removed from the MassHealth Drug List because it has been discontinued by the manufacturer.	
sumatriptan and naproxen                       (Treximet) 	Addition; requires PA	There are more cost-effective alternatives available for the management of the same clinical conditions including naproxen  as a generic single-entity product.	

Recent MassHealth Drug List Updates are continued on next page.

Drug/Drug Class	Addition/Deletion/Change	Rationale	
telithromycin    (Ketek)	Change in PA status; requires PA
	There are clinically appropriate alternatives available for management of the same clinical conditions. 	
valproic acid   (Stavzor)	Addition; requires PA	There are more cost-effective alternatives available for the management of the same clinical conditions including generic valproic acid and divalproex sodium. 	
voriconazole     (VFend)	Change in PA status; requires PA
	Voriconazole is considered a second-line therapy in certain indications. Therefore, prior authorization will be required.  	
zileuton                
(Zyflo) 	Deletion; no longer on MassHealth Drug List	This product has been removed from the MassHealth Drug List because it has been discontinued by the manufacturer.	

Please send any suggestions or comments to:  PrescriberELetter@state.ma.us