Commonwealth of MassachusettsMassHealth Drug Utilization Review ProgramP.O. Box 2586 Worcester, MA 01613-2586
Fax: 1-877-208-7428 Phone: 1-800-745-7318
Anticonvulsant Prior Authorization Request
MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other insurance, and program restrictions. MassHealth will notify the requesting provider and member of its decision. Keep a copy of this form for your records. If faxing this form, please use black ink.
PA is required for Banzel (solution, tablet), clonazepam ODT (generics, Klonopin Wafers), diazepam powder, diazepam rectal gel > 5 kits (10 syringes/month), Keppra XR, Lamictal ODT, Lamictal ODT Starter Kit, Lamictal XR, Lamictal XR Starter Kit, lamotrigine Starter Kit, lorazepam powder, Lyrica, ONFI, phenytoin unit dose suspension, Sabril, Stavzor, and Vimpat (solution, tablet). PA is required for Gabitril and gabapentin powder for members > 19 years of age. Additional information about anticonvulsants, including PA requirements, can be found within the MassHealth Drug List at www.mass.gov/druglist.
First name MI MassHealth member ID no. Date of birth Gender (Check one.)
Medication information: Section I (Please complete for all requests.)
Anticonvulsant request (Check one or all that apply.) Dose, frequency, and duration of requested drug Drug NDC (if known) or service code
Indication for anticonvulsant requested (Check one or all that apply.)
clonazepam ODT (generics, Klonopin Wafers)
diazepam rectal gel > 5 kits (10 syringes/month)
Gabitril (tiagabine) > 19 years of age
Keppra XR (levetiracetam extended-release)
(lamotrigine orally disintegrating tablet)
Please list all other medications currently prescribed for the member for this indication.
lorazepam powder, lamotrigine Starter Kit Lyrica (pregabalin) ONFI (clobazam)
Is member under the care of a neurologist? Yes No
Is member under the care of a psychiatrist? Yes No
Sabril (vigabatrin) Stavzor (valproic acid) Vimpat (lacosamide) solution, tablet
Medication information: Section II (Please complete for requests for Banzel, ONFI, Sabril, and Vimpat.)
Please list other anticonvulsants tried by this member including dates and outcomes.
Medication information: Section III (Please complete for requests for clonazepam ODT, diazepam powder, diazepam rectal gel, gabapentin
powder, Lamictal ODT, Lamictal XR, lorazepam powder, Keppra XR, phenytoin suspension, and Stavzor.)
Please attach a letter describing the medical necessity for the use of the requested product. Include prior trials of agents as appropriate.
Medication information: Section IV (Please complete for requests for Lyrica.)
For requests for seizure disorders, please complete question 1. For requests for fibromyalgia, please complete questions 2-4. For requests for
diabetic peripheral neuropathy or postherpetic neuralgia, please complete questions 2 and 3.
1. Has the member experienced a documented inadequate response to one other option for seizures including: carbamazepine, gabapentin,
lamotrigine, levetiracetam, oxcarbazepine, topiramate, valproic acid or divalproex sodium, or zonisamide?
No. Explain medical necessity for the use Lyrica:
2. Has the member experienced an inadequate response or adverse reaction to a tricyclic antidepressant, an SSRI/SNRI-type antidepressant,
No. Explain why a tricyclic antidepressant, an SSRI/SNRI-type antidepressant, and cyclobenzaprine have not been tried.
3. Has the member experienced an inadequate response (two weeks of therapy at 1,200 mg/day), adverse reaction, or contraindication
No. Explain why gabapentin has not been tried:
4. Has the member experienced an inadequate response, adverse reaction, or contraindication to Savella?
No. Explain why Savella has not been tried:
Prescribing provider’s attestation, signature, and date
I certify under the pains and penalties of perjury that I am the prescribing provider identified in the prescriber information section of this form. Any attached statement on my letterhead has been reviewed and signed by me. I certify that the medical necessity information (per 130 CMR 450.204) on this form is true, accurate, and complete, to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.
Prescribing provider’s signature (Signature and date stamps, or the signature of anyone other than the provider, are not acceptable.):
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