Current information for pharmacists about the MassHealth Pharmacy program
MassHealth Pharmacy Program
Number 74
November 29, 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 list of updates. 

1. Additions 

The following newly marketed drugs have been 
added to the MassHealth Drug List as of 
November 13, 2012. 

Dymista (azelastine/fluticasone propionate) – PA 
Kyprolis (carfilzomib) – PA 
Omeclamox-Pak (omeprazole/clarithromycin / 
amoxicillin) – PA 
Perjeta (pertuzumab) – PA 
Sklice (ivermectin lotion) – PA 
Ultravate X (halobetasol/lactic acid) – PA 
Viokace (lipase/protease/amylase) 
Zyclara (imiquimod 2.5% cream) – PA 

2. Change in Prior Authorization Status 

a. The prior-authorization requirement for the 
following drug has changed. The new prior-
authorization requirement as shown below is 
effective November 13, 2012. 

Cervarix (human papillomavirus bivalent vaccine)1, 2 

 – PA < 9 years and PA = 26 years 

 b. The following drugs require prior authorization 
effective November 26, 2012. 
buspirone 30 mg – PA 
Crinone (progesterone gel) – PA 

3. Updated MassHealth Over-the-Counter Drug 
List 

The MassHealth Over-the-Counter Drug List has 
been updated to reflect recent changes to the 
MassHealth Drug List. 

a. The following drug has been removed from the 
Over-the-Counter Drug List because it has been 
discontinued by the manufacturer. 
Commit (nicotine) = 180 days treatment/year 

b. The following listing has been clarified. 

 Nicotine replacement therapy < 180 days 
 treatment/year 

4. Updated Medicare Part D Exclusion Drug List 

The following updates are effective January 13, 2013 
and will be reflected on the MHDL in a future update. 

a. Benzodiazepines will no longer be excluded by 
Medicare Part D. 

b. Barbiturates will no longer be excluded by 
Medicare Part D for certain medical conditions. 

5. Corrections 

a. The following drug has been added to the 
MassHealth Drug List. It was omitted in error. 
This does not reflect any change in MassHealth 
policy. 


Altace # (ramipril) 


b. The following listings have been clarified. 

Androgel (testosterone 1.62% pump, packets) – PA 
Fabrazyme (agalsidase beta) – PA 
Lumizyme (alglucosidase alfa) – PA 
Myozyme (alglucosidase alfa) – PA 
Sarafem # (fluoxetine 10 mg tablet) 
Sarafem (fluoxetine 20 mg tablet) – PA 
Stromectol (ivermectin tablet) 

# 
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. 

 1 Product may be available 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 the Massachusetts 
Department of Public Health without prior authorization (130 CMR 
406.413(C)). In cases where free vaccines are available to providers 
for specific populations (e.g. children, high risk, etc.), MassHealth 
will reimburse the provider only for individuals not eligible for the free 
vaccines. Notwithstanding the above, MassHealth will pay 
pharmacies for seasonal flu vaccine serum without prior 
authorization, if the vaccine is administered in the pharmacy. 

2 Prior authorization status is gender specific. 



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