Formulary Coverage Changes Effective April 1, 2020

Affected members will be notified 

January 22, 2020  

The following formulary coverage changes are effective April 1, 2020. The changes apply to both Tufts Health Plan and Tufts Health Freedom Plan:

  1. These cough and cold products will have quantity limitations, which are in line with recommended dosing:
    • Ambitussin (guaifenesin, codeine phosphate) 100-10 mg/5 mL solution
    • CGU WC (guaifenesin, codeine phosphate) 100-6.3 mg/5 mL solution
    • Codar® GF (guaifenesin, codeine phosphate) 200-8 mg/5 mL liquid
    • Coditussin AC (guaifenesin, codeine phosphate) 200-10 mg/5 mL liquid
    • Coditussin DAC (pseudoephedrine HCl, codeine phosphate, guaifenesin) liquid
    • hydrocodone polistirex - chlorpheniramine polisitrex extended release oral suspension
    • Hydromet (hydrocodone bitartrate-homatropine methylbromide) 5-1.5 mg/5 mL syrup
    • Lortuss EX (pseudoephedrine HCl, codeine phosphate, guaifenesin) 30-10-100 mg/5 mL liquid
    • Mar-Cof® CG (guaifenesin, codeine phosphate) 225-7.5 mg/5 mL liquid
    • Promethazine VC/Codeine (promethazine HCl, phenylephrine HCl, codeine phosphate) 6.25-5-10 mg/5 mL syrup
    • Promethazine - codeine 6.25-10 mg/5 mL syrup
    • Suttar-2 (pseudoephedrine HCl, codeine phosphate, guaifenesin) 30-10-100 mg/5 mL) syrup
    • Tussicaps® (hydrocodone polistirex, chlorpheniramine polistirex) extended release capsules
    • Tussigon (hydrocodone HCl, homatropine methylbromide) 5-1.5 mg tablets
    • Tuzistra® XR (codeine polistirex - chlorpheniramine polistirex) 14.7-2.8 mg/5 mL extended release suspension
    • Virtussin DAC (codeine phosphate, guaifenesin, pseudoephedrine) liquid
    • Z-TussTM AC (chlorpheniramine maleate, codeine phosphate) 2-9 mg/5 mL liquid

  2. The following drugs will be moving to Non-Covered (Large Group):
    Drugs moving to not covered Lower tier alternative drug* Tier of alternative
    Afinitor® (everolimus) 2.5, 5, 7.5 mg
     
    everolimus tablets Tier 2/Tier 4
    Dyrenium®
    (triamterene)
     
    triamterene capsules Tier 2
    Halog® (halcinonide) cream
     
    fluocinonide 0.05% cream Tier 1
    Jadenu® (deferasirox) 90, 360 mg
     
    deferasirox tablets Tier 2
    NorgesicTM Forte (orphenadrine citrate, aspirin and caffeine)
     
    orphenadrine w/aspirin & caffeine tablets Tier 2
    Orfadin® (nitisinone) capsules
     
    nitisinone capsules Tier 2/Tier 4
    Sensipar® (cinacalcet)
     
    cinacalcet Tier 2
    Soolantra® (ivermectin) 1% cream
     
    ivermectin 1% cream Tier 2
    Tuzistra® XR (codeine polistirex and chlorpheniramine polistirex) promethazine/codeine Tier 1

  3. The following drugs will be placed on the Specialty Pharmacy list:
    • Cayston® (aztreonam)
    • octreotide acetate

  4. The following products will be excluded from coverage:
    • Antituss CG/Codeine (phenylephrine HCL, chlorpheniramine maleate, codeine phosphate) syrup
    • cetirizine-pseudoephedrine extended release 5-120 mg tablets
    • dextromethorphan-guaifenesin extended release 60-1,200 mg tablets
    • dextromethorphan-phenylephrine-acetaminophen 10-5-325 mg/15 mL liquid
    • HistexTM-AC (phenylephrine HCL, triprolidine HCL, codeine) 10-2.5-10 mg/5 mL syrup
    • Mar-cof® BP (pseudoephedrine HCL, brompheniramine maleate, codeine phosphate) 30-2-7.5 mg/5 mL liquid
    • Maxi-Tuss CD (chlorpheniramine maleate, codeine phosphate, phenylephrine HCL) 10-4-10 mg/5 mL liquid
    • M-End PE (codeine phosphate, phenylephrine hydrochloride, brompheniramine maleate) 3.33-1.33-6.33 mg/5 mL liquid
    • M-End WC (codeine phosphate, pseudoephedrine hydrochloride, brompheniramine maleate) 10-1.33-6.33 mg/5 mL liquid
    • Poly-Tussin (brompheniramine maleate, codeine phosphate, phenylephrine HCL) 10-4-10 mg/5 mL liquid
    • Pro-Red AC (codeine phosphate, dexchorpheniramine maleate, phenylephrine HCL) 5-1-9 mg/5 mL syrup
    • Sandostatin® LAR Depot (octreotide acetate)
    • Semprex®-D (acrivastine and pseudoephedrine HCL) capsules

  5. The following drugs will be moving to Non-Covered (Tufts Health Freedom Plan only):
    Drugs moving to not covered Lower tier alternative drug* Tier of alternative
    Dyrenium® (triamterene) capsules
     
    triamterene capsules Tier 2
    Halog® (halcinonide) cream
     
    fluocinonide 0.05% cream Tier 1
    NorgesicTM Forte
    (orphenadrine citrate, aspirin and caffeine) tablets
     
    orphenadrine w/aspirin & caffeine tablets Tier 2
    Orfadin® (nitisinone) capsules
     
    nitisinone capsules Tier 2/Tier 4
    Soolantra® (ivermectin) 1% cream
     
    ivermectin 1% cream Tier 2
    Tuzistra® XR (codeine
    polistirex and
    chlorpheniramine polistirex) oral suspension
    promethazine/codeine oral syrup Tier 1

  6. The following drug will require Prior Authorization:
    • Descovy® (emtricitabine and tenofovir alafenamide)

  7. Famotidine will be moved up to Tier 3.

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