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MassHealth Formulary

The MassHealth Pharmacy Program, in collaboration with the Department of Children and Families (DCF) and the Department of Mental Health (DMH), have developed a Pediatric Behavioral Health Medication Initiative (PBHMI) that requires prior authorization for pediatric members (generally members less than 18 years of age) for certain behavioral health medication classes and/or specific medication combinations (i.e., polypharmacy) that have limited evidence for safety and efficacy in the pediatric population.  AllWays Health Partners has adopted this initiative.  For specific criteria, please click here.


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*5-ht4 receptor agonists****adenosine deaminase scid treatment - agents****adenosine receptor antagonist****adhd/anti-narcolepsy/anti-obesity/anorexiants**agents for narcotic withdrawal****agents for opioid withdrawal****als agents - miscellaneous****aminoglycosides**aminomethylcyclines****analgesics - anti-inflammatory**analgesics - nonnarcotic**analgesics - opioid**androgens-anabolic**anorectal agents**antacids**anthelmintics**antianginal agents**antianxiety agents**antiarrhythmics**antiasthmatic and bronchodilator agents**anticoagulants**anticonvulsants**antidementia agent combinations****antidepressants**antidiabetics**antidiarrheal/probiotic agents**antidiarrheals**antidotes**antiemetics**antifungals**antihemophilic products - monoclonal antibodies****antihistamines**antihyperlipidemics**antihypertensives**anti-infective agents - misc.**antimalarials**antimyasthenic agents**antimyasthenic/cholinergic agents**antimycobacterial agents**antineoplastic - bcl-2 inhibitors****antineoplastic - bispecific t-cell engagers****antineoplastic - fgfr kinase inhibitors****antineoplastic - tropomyosin receptor kinase inhibitors****antineoplastic - xpo1 inhibitors****antineoplastics and adjunctive therapies**antiparkinson agents**antipsychotics/antimanic agents**antiretrovirals - cd4-directed post-attachment inhibitor****antiretrovirals adjuvants****antiseptics & disinfectants**antivirals**anti-von willebrand factor agents****assorted classes**atopic dermatitis - monoclonal antibodies****bacterial monoclonal antibodies****beta blockers**biologicals misc**calcitonin gene-related peptide (cgrp) receptor antag****calcium channel blockers**cardiotonics**cardiovascular agents - misc.**cephalosporins**cgrp receptor antagonists - monocolonal antibodies****cic agents - guanylate cyclase-c (gc-c) agonists****contraceptives**corticosteroids**cough/cold/allergy**cyclin-dependent kinases (cdk) inhibitors****cystic fibrosis agent - combinations****dermatologicals**diagnostic products**digestive aids**direct-acting p2y12 inhibitors****diuretics**dopamine and norepinephrine reuptake inhibitors (dnris)****endocrine and metabolic agents - misc.**erythroid maturation agents****estrogens**estrogen-selective estrogen receptor modulator comb****farnesoid x receptor (fxr) agonists****fluoroquinolones**gaba receptor modulator - neuroactive steroid****gastrointestinal agents - misc.**genitourinary agents - miscellaneous**glycopeptides****gout agents**hematological agents - misc.**hematopoietic agents**hemoglobin s (hbs) polymerization inhibitors****hemostatics**hepatitis c agent - combinations****hypnotics**ibs agent - mu-opioid receptor agonists****in vitro/lock anticoagulants****integrin receptor antagonists****interleukin antagonists****interleukin-5 antagonists (igg1 kappa)****interleukin-5 antagonists (igg4 kappa)****isocitrate dehydrogenase-1 (idh1) inhibitors****laxatives**lhrh/gnrh agonist analog combinations****local anesthetics-parenteral**lymphocyte function-associated antigen-1 (lfa-1) antag****lysosomal acid lipase (lal) deficiency - agents****macrolides**medical devices**migraine products**minerals & electrolytes**mixed allergenic extracts****monobactams****mouth/throat/dental agents**mucopolysaccharidosis iv (mps iv) - agents****mucopolysaccharidosis vii (mps vii) - agents****multiple sclerosis agents - antimetabolites****multivitamins**muscular dystrophy agents****musculoskeletal therapy agents**nasal agents - systemic and topical**neprilysin inhib (arni)-angiotensin ii recept antag comb****neuromuscular agents**n-methyl-d-aspartic acid (nmda) receptor antagonists****nutrients**ophthalmic agents**ophthalmic kinase inhibitors - combinations****ophthalmic nerve growth factors****ophthalmic rho kinase inhibitors****orexin receptor antagonists****otic agents**oxytocics**pa endonuclease inhibitors****passive immunizing agents - combinations****passive immunizing agents**pcsk9 inhibitors****pediatric multiple vitamins w/fluoride-iron-zinc****penicillins**pharmaceutical adjuvants**phosphatidylinositol 3-kinase (pi3k) inhibitors****phosphodiesterase 4 (pde4) inhibitors - topical****phosphodiesterase 4 (pde4) inhibitors****plasma kallikrein inhibitors - monoclonal antibodies****pleuromutilins****poly (adp-ribose) polymerase (parp) inhibitors***poly (adp-ribose) polymerase (parp) inhibitors****potassium removing agents****progestins**psychotherapeutic and neurological agents - misc.**pulmonary fibrosis agents - kinase inhibitors****pulmonary fibrosis agents****pulmonary hypertension - prostacyclin receptor agonist****respiratory agents - misc.**selectin blockers****serotonin modulators****sglt2 inhibitor - dpp-4 inhibitor - biguanide comb****sglt2 inhibitor - dpp-4 inhibitor combinations****sinus node inhibitors***small interfering ribonucleic acid (sirna) agents****sodium-glucose co-transporter 2 inhibitor-biguanide comb****spinal muscular atrophy-antisense oligonucleotides****spleen tyrosine kinase (syk) inhibitors****steroids - mouth/throat/dental****sulfonamides**tetracyclines**tetrahydroisoquinolines****thyroid agents**toxoids**transthyretin stabilizers****tripeptidyl peptidase 1 deficiency treatment - agents****tryptophan hydroxylase inhibitors****ulcer drugs**urinary anti-infectives**urinary antispasmodics**vaccines**vaginal products**vasopressors**vitamins**x-linked hypophosphatemia (xlh) treatment - agents***
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Formulary Id: 00000000
Formulary Effective Date: 01/01/2020
Updated:
10/2020

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