Current information for pharmacists about the MassHealth Pharmacy Program

MassHealth Pharmacy Program

Number 77
March 14, 2013

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 Update

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 March 11, 2013.

AUBAGIO (teriflunomide) – PA
Linzess (linaclotide) – PA
SYNRIBO (omacetaxine mepesuccinate) – PA
XELJANZ (tofacitinib) – PA

2. Change in Prior-Authorization Status

a. The following generic drugs are covered without prior authorization.
Cozaar # (losartan)
Hyzaar # (losartan/hydrochlorothiazide)

b. The following drugs will require prior authorization effective March 25, 
2013.

Adagen (pegademase bovine) – PA
Cedax (ceftibuten) – PA
Spectracef (cefditoren) – PA
Suprax (cefixime) – PA

c. The following drugs will require prior authorization when prescribed to 
members above or below the ages indicated below, effective March 25, 2013.

Asmanex (mometasone 110 mcg, inhaler) – PA > 12 years
Asmanex (mometasone 220 mcg, inhaler) – PA < 12 years
Isentress (raltegravir 25 mg and 100 mg) – PA > 12 years

d. The following drugs will be added to the MassHealth Drug List and will be 
available only through the health-care professional who administers the drug. 
MassHealth does not pay for these drugs to be dispensed through a retail 
pharmacy, effective March 25, 2013.

Anascorp (centruroides immune F(ab’)2, equine) ^
BAL in Oil (dimercaprol) ^
Carbocaine (mepivacaine) ^
chloroprocaine ^

3. MassHealth Non-Drug Product List

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

Synvisc-One (hylan G-F 20) – PA

b. The following listings have been clarified. These changes do not reflect 
any change in MassHealth policy.
Orthovisc (high molecular weight hyaluronan) – PA
Synvisc (hylan G-F 20) – PA

4. Corrections and Clarifications

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.

amifostine
amphotericin B
cladribine
Corifact (factor XIII concentrate, human)
dactinomycin
daunorubicin, conventional
dimenhydrinate injection
Doxil (liposomal doxorubicin)
Erythrocin (erythromycin IV)
floxuridine
fosphenytoin
Gamastan (immune globulin, human) – PA
HepaGam B (hepatitis B immune globulin, human)
Hylenex (hyaluronidase, human recombinant)
idarubicin
Lipodox (doxorubicin liposomal injection)
magnesium sulfate
Octagam (immune globulin, human) – PA
pentostatin
ranitidine injection
Rimso-50 (dimethyl sulfoxide)
ringers solution, lactated
sodium chloride solution
Trisenox (arsenic trioxide)
Vitrase (hyaluronidase, ovine)
Vumon (teniposide)
Zanosar (streptozocin)

(continued on next page)

b. The following listings have been clarified. These 
changes do not reflect any change in MassHealth policy. 

Concerta (methylphenidate ER 18 mg) – PA 
Dilantin # (phenytoin capsule, suspension) 
hydrocodone/acetaminophen – PA > 4 grams of 
acetaminophen/day 
Isentress (raltegravir 400 mg) 
mitomycin injection 
NutreStore (l-glutamine) – PA 
Protonix # (pantoprazole 20 mg tablet) – PA > 30 
units/month 
Protonix # (pantoprazole 40 mg tablet) – PA > 60 
units/month 
Protonix (pantoprazole 40 mg suspension) – PA > 30 
units/month 

# 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. 

^ 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 of this fax 
distribution) to Victor Moquin of ACS at 617-423-9830.