Pharmacy Coverage Changes

Commercial products (including Tufts Health Freedom Plan), Tufts Health Direct

October 30, 2020  

The following changes apply to Commercial products (including Tufts Health Freedom Plan) and Tufts Health Direct and are effective for fill dates on or after January 1, 2021, unless otherwise noted.

BD Insulin Syringes and Pen Needles Preferred

Effective for fill dates on or after January 1, 2021, Tufts Health Plan will prefer the BD insulin syringes and BD pen needles for Commercial products (including Tufts Health Freedom Plan) and Tufts Health Direct.

Note: This change applies to all members. Members who are using BD insulin syringes and pen needles for their current treatment will be able to continue to do so. All other brands of insulin syringes and pen needles will be noncovered. For these requests, the prescribing provider can write a new prescription for BD insulin syringes and pen needles or must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Non-Covered Drugs with Suggested Alternatives.

Blood Glucose Monitors: Free Meter Program

Effective for fill dates on or after January 1, 2021, blood glucose monitors will be moved to excluded status for Commercial products (including Tufts Health Freedom Plan) and Tufts Health Direct.

The CDC recommends that members with diabetes use a blood glucose monitor, or glucometer, to check their blood sugar. Members are eligible to obtain a free OneTouch® glucometer every plan year via CVS Caremark's Diabetic Free Meter Program by calling 800.588.4456. Members will need to provide their Tufts Health Plan member ID number and their prescriber's name and fax number. A representative will help the member order a free glucometer and get a new prescription for test strips. The glucometer will be mailed to the member.

If preferred, members could instead obtain a free OneTouch Verio Flex® meter at an in-network pharmacy via the Pharmacist Meter Voucher Program. Providers can write a prescription for their patients and instruct them to bring the prescription to an in-network pharmacy where the meter can be provided at no cost to the member.

Note: Glucometers should be replaced every one to two years. Members are eligible to receive a free replacement through the CVS Caremark Diabetic Meter Program once every plan year.

Specialty Infusion and Specialty Pharmacy Programs

Effective for fill dates on or after January 1, 2021, Cutaquig® (immune globulin subcutaneous [human]-hipp, 16.5% solution) will be added to the specialty infusion program for Commercial products (including Tufts Health Freedom Plan) and the specialty pharmacy program for Tufts Health Direct.

Human Immunodeficiency Virus (HIV)

Tufts Health Plan is considering changes to the coverage of drugs used for the treatment of HIV, to be effective on or after January 1, 2021, for Commercial products (including Tufts Health Freedom Plan).

More information, including a list of drugs affected by this change (if any), will be available in the News section on Tufts Health Plan’s public Provider website, prior to this date. For questions, call Provider Services at 888.884.2404.

The following changes apply to all Commercial products (including Tufts Health Freedom Plan) and are effective for fill dates on or after January 1, 2021:

Drugs Moving to Tier 1 Status

  • ampicillin capsules
  • chlorzoxazone tablets
  • losartan/HCTZ tablets
  • propranolol tablets

Prior Authorization

New Prior Authorization Programs
Effective for fill dates on or after January 1, 2021, Tufts Health Plan will add prior authorization criteria for Denavir (penciclovir) cream and Proleukin® (aldesleukin). These coverage changes apply to members currently utilizing Denavir (penciclovir) cream and Proleukin (aldesleukin) and members initiating a new course of treatment. Members who are already taking this drug during their current course of treatment will be able to continue to do so without prior authorization. For these requests, the prescribing provider must request coverage through the medical review process subject to the applicable pharmacy medical necessity guidelines.

Changes to Existing Prior Authorization Programs
Effective for prior authorization requests submitted on or after January 1, 2021, Tufts Health Plan will update its prior authorization criteria for the following:

  • Botulinum Toxins
  • Complement Inhibitors (Soliris®, Ultomiris®)
  • Increlex® (mecasermin)
  • Migraine Medications: CGRP Receptor Antagonists and More
  • Oral Cancer Medications
  • Overactive Bladder Medications
  • Parathyroid Hormone Analogs
  • Prolia® and Xgeva® (denosumab)

For these requests, the prescribing provider must request coverage through the medical review process subject to the applicable pharmacy medical necessity guidelines.

Quantity Limitations

Effective for fill dates on or after January 1, 2021, Tufts Health Plan will have new quantity limitations for Trelegy Ellipta. For a member to receive coverage for quantities above the new limit, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Drugs with Quantity Limitations.

Drug Status Changes

The following changes apply to Commercial products (including Tufts Health Freedom Plan) and Tufts Health Direct and are effective for fill dates on or after January 1, 2021:

Drugs Moving to Noncovered Status

  • Azelex® 20% cream
  • Bethkis nebulizer solution
  • Ciprodex® suspension
  • clindamycin phosphate-tretinoin 1.2-0.25 gel
  • Demser® capsules
  • doxycycline monohydrate 40mg DR capsule
  • Forteo® (teriparatide)
  • Jadenu® Sprinkle tablets/granules
  • ketoprofen capsule
  • ketoprofen ER capsule
  • MoviPrep
  • naproxen CR tablet
  • Noritate® (metronidazole) 1% cream
  • Protonix® Suspension Packets
  • Ridaura capsule
  • Samsca® 30mg tablet
  • Ubrelvy TM tablets

Drugs Moving to Excluded Status

  • Baclofen powder
  • Carbidopa powder
  • ceftazidime vials
  • ciprofloxacin injection
  • meropenem injection
  • piperacillin-tazobactam injection
  • tobramycin vials
  • Topical Benzoyl Peroxide
  • Topical Sulfacetamide Sodium combinations

Drugs Moving to Tier 3

  • dapsone 7.5% gel
  • ethacrynic acid tablet
  • Fluoroplex® (fluorouracil) 1% cream
  • fluorouracil 0.5% cream
  • frovatriptan tablet
  • lanthanum chewable tablet
  • naproxen 125mg/5mL suspension
  • nitrofurantoin 25mg/5ml suspension
  • sumatriptan-naproxen 85-500mg tablet
  • Synarel® (nafarelin) 2mg/ml nasal solution

Drugs Moving to Tier 2

  • acyclovir suspension
  • alosetron tablet
  • chlorpromazine tablet
  • clarithromycin suspension
  • erythromycin 2% gel
  • erythromycin tablet and capsule
  • erythromycin-benzoyl peroxide 3%-5% gel
  • fluphenazine tablet
  • nadolol tablet
  • prednisolone ODT tablet
  • sumatriptan nasal sprays and injections
  • terconazole vaginal suppository
  • tizanidine capsule
  • ursodiol capsule
  • valganciclovir tablet

Large Groups
The following changes apply to large-group Commercial products (including Tufts Health Freedom Plan) and are effective for fill dates on or after January 1, 2021:

Drugs Moving to Noncovered Status

  • Lovenox® syringes (brand)
  • Revatio® (sildenafil)
  • Trulance® tablets

Drugs Moving to Tier 3

  • Emtriva® capsules
  • Symfi
  • Symfi Lo

Small Groups
The following drugs are moving to noncovered status. These changes apply to small-group Commercial products and are effective for fill dates on or after January 1, 2021:

  • Emtriva® capsules
  • Renvela® 800mg tablets
  • Symfi
  • Symfi Lo

Small Groups – New Hampshire
The following drugs are moving to noncovered status. These changes apply to small-group Commercial New Hampshire products and are effective for fill dates on or after January 1, 2021:

  • Afinitor® 2.5, 5 and 7.5mg tablets
  • Apriso capsules
  • Daraprim® tablets
  • Depen titratabs
  • Jadenu® tablets
  • Sensipar® tablets
  • Zortress® tablets

3-Tier Formularies
The following changes apply to 3-tier Commercial products and are effective for fill dates on or after January 1, 2021:

  • Granix® (tbo-filgrastim)
  • Neupogen® (filgrastim) vials
  • Nivestym® (filgrastim-aafi)

4-Tier Formularies
The following changes apply to 4-tier Commercial products and are effective for fill dates on or after January 1, 2021:

  • bexarotene
  • everolimus 0.25mg, 0.5mg and 0.75mg tablets
  • Cystaran® (cysteamine)
  • Mesnex® (mesna)
  • Ravicti (glycerol phenylbutyrate)
  • Sancuso® (granisetron)

Tufts Health Direct
The following drugs are moving to noncovered status. These changes apply to Tufts Health Direct products and are effective for fill dates on or after January 1, 2021:

  • Emtriva® capsules
  • Renvela® 800mg tablets
  • Symfi
  • Symfi Lo

Continuous Glucose Monitors (CGMs)

Effective for fill dates on or after January 1, 2021, Tufts Health Plan will no longer cover CGMs and their accompanying supplies through durable medical equipment (DME) suppliers for Tufts Health Direct. All CGMs and their accompanying supplies will be covered with prior authorization and will be available through the pharmacy only with a prescription under the pharmacy benefit. Dexcom G6® and its supplies will continue to require prior authorization and will be reviewed against criteria in the Pharmacy Medical Necessity Guideline for Devices for the Management of Diabetes – Continuous Monitoring Systems. Dexcom G4®, Dexcom G5®, FreeStyle® Libre and Medtronic Guardian™ will be noncovered. For a member to continue using any of these drugs, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Non-Covered Drugs with Suggested Alternatives. Should a request for any of these drugs be approved, members will have to fill their CGM and its supplies at the pharmacy as they will not be available through the DME supplier. All CGMs will be restricted with quantity limitations. For these requests, the prescribing provider must request coverage through the medical review process subject to the applicable pharmacy medical necessity guidelines via the Pharmacy Utilization Management Department fax at 617.673.0988.