Pharmacy Coverage Changes

Tufts Health RITogether, Tufts Health Together

October 30, 2020  

The following changes apply to Tufts Health RITogether and Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans (ACPPs) and are effective for fill dates on or after January 1, 2021, unless otherwise noted.

Prior Authorization

New Prior Authorization Programs
Proleukin® (aldesleukin): Tufts Health RITogether and Tufts Health Together – MassHealth MCO Plan and ACPPs
Effective for fill dates on or after January 1, 2021, Tufts Health Plan will require prior authorization for coverage of Proleukin (aldesleukin).

Note: This change applies to 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 Pharmacy Medical Necessity Guidelines for Proleukin (aldesluekin). In addition, effective for fill dates on or after January 1, 2021, Proleukin (aldesleukin) will be excluded under the pharmacy benefit. Coverage will remain on the medical benefit only.

Concomitant Opioid and Benzodiazepine Initiative (COBI): Tufts Health Together MassHealth MCO Plan and ACPPs
Effective for fill dates on or after January 1, 2021, Tufts Health Plan will implement MassHealth’s COBI for Tufts Health Together – MassHealth MCO Plan and ACPPs. As part of COBI, members who fill opioid and benzodiazepine medications concomitantly for at least 60 days, within a 90-day period, will require prior authorization for their benzodiazepine medication. The goal of COBI is to focus on safe prescribing practices for members who are using opioids and benzodiazepines together. Members who are currently administered an opioid and benzodiazepine concomitantly will not be allowed to continue without prior approval. For a list of active ingredients included in COBI as well as the prior authorization approval criteria, refer to the Pharmacy Medical Necessity Guidelines for Anti-Anxiety Medications (Benzodiazepines and Buspirone) for Tufts Health Together – MassHealth MCO Plan and ACPPs.

Donepezil, Memantine, Naltrexone Tablet: Tufts Health Together – MassHealth MCO Plan and ACPPs
Effective for fill dates on or after January 1, 2021, Tufts Health Plan will require prior authorization for coverage of donepezil, memantine and naltrexone tablets when prescribed for members less than 6 years of age. This is part of MassHealth’s Pediatric Behavioral Health Medication Initiative (PBHMI). Donepezil, memantine and naltrexone tablets will also be included in the polypharmacy component of PBHMI, requiring prior authorization if a member less than 18 years of age has pharmacy claims for four or more behavioral health medications in a 45-day period.

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 medications and programs listed below. These changes will apply to new requests for prior authorization for one of these medications. For these requests, the prescribing provider must request coverage through the medical review process subject to the applicable pharmacy medical necessity guidelines below:

Tufts Health RITogether and Tufts Health Together – MassHealth MCO Plan and ACPPs

  • Complement Inhibitors (Soliris®, Ultomiris™)
  • Gastrointestinal Medications
  • Gonadotropin-releasing Hormone (GnRH) Agonists
  • Increlex (mecasermin)
  • Oral Cancer Medications
  • Parathyroid Hormone Analogs
  • Prolia® and Xgeva® (denosumab)

Tufts Health Together – MassHealth MCO Plan and ACPPs

  • Analeptic CNS Stimulants: Modafinil and Armodafinil
  • Anti-Anxiety Medications (Benzodiazepines and Buspirone)
  • Glaucoma Medications
  • Pediatric Behavioral Health Medication Initiative (PBHMI) Polypharmacy

Tufts Health RITogether

  • Anti-Emetic Medications

Drugs Status Changes

Drugs Moving to Noncovered Status
Effective for fill dates on or after January 1, 2021, Tufts Health Plan will move the following medications to noncovered status. For a member to continue taking any of the medications moving to noncovered status, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Pharmacy Products Without Specific Criteria for Tufts Health RITogether and Non-Covered Pharmacy Products for Tufts Health Together – MassHealth MCO Plan and ACPPs.

To submit a prior authorization request for any medications moving to noncovered status, complete the Tufts Health Plan Medication Prior Authorization Form for Tufts Health RITogether and Tufts Health Together – MassHealth MCO Plan and ACPPs. This form can be faxed or mailed to Tufts Health Plan’s Pharmacy Utilization Management Department, as indicated on the form.

Tufts Health RITogether and Tufts Health Together – MassHealth MCO Plan and ACPPs

  • Ethacrynic acid
  • Evzio® (naloxone auto injector)
  • Forteo® (teriparatide injection)

Note: Bumetanide, furosemide and torsemide will continue to be covered without prior authorization.

Note: Narcan® (naloxone) nasal spray and generic naloxone injection will continue to be covered without prior authorization.

Tufts Health Together – MassHealth MCO Plan and ACPPs

  • Trulance® (plecanatide) tablet
  • Zioptan® (tafluprost ophthalmic solution) 0.0015%

Note: Effective for fill dates on or after January 1, 2021, Amitiza® (lubiprostone) will be covered with prior authorization.

Note: Generic latanoprost (Xalatan) 0.005% ophthalmic solution will continue to be covered without prior authorization. Effective January 1, 2021, generic travoprost (Travatan® Z) 0.004% ophthalmic solution and bimatoprost (generic Lumigan®) 0.03% ophthalmic solution will be covered without prior authorization.

Tufts Health RITogether

  • Asmanex® HFA (mometasone furoate)
  • Asmanex® Twisthaler® (mometasone furoate inhalation powder)
  • Flovent® Diskus® (fluticasone propionate inhalation powder)
  • Flovent® HFA (fluticasone propionate inhalation aerosol)
  • Humalog® Mix75/25™ (insulin lispro protamine/insulin lispro) vial
  • Humalog® Mix75/25™ (insulin lispro protamine/insulin lispro) KwikPen®
  • NovoLog® Mix 70/30 (insulin aspart protamine/insulin aspart) vial
  • NovoLog® Mix 70/30 (insulin aspart protamine/insulin apart) FlexPen®
  • Pulmicort Flexhaler™ (budesonide inhalation powder)

Note: Alvesco® (ciclesonide inhalation aerosol) and Qvar RediHaler® (beclomethasone dipropionate HFA) will continue to be covered without prior authorization. Effective for fill dates on or after January 1, 2021, Arnuity® Ellipta® (fluticasone furoate inhalation powder) will also be covered without prior authorization.

Note: The authorized generics for Humalog® Mix75/25™ KwikPen®, NovoLog® Mix 70/30 vial and FlexPen® will continue to be covered without prior authorization. Providers should begin transitioning patients to the authorized generics to avoid disruptions of care. The authorized generics may not be automatically interchanged for the brand agents at the pharmacy, so providers should specify the generic on the prescription.

Specialty Pharmacy Program

Effective for fill dates on or after January 1, 2021, Veletri® (epoprostenol) will be added to the specialty pharmacy program for Tufts Health Together – MassHealth MCO Plan and ACPPs.

Tufts Health Together Coverage Changes

Effective for fill dates on or after January 1, 2021, for Tufts Health Together – MassHealth MCO Plan and ACPPs, coverage changes and/or changes in prior authorization requirements may occur for select medications within the following therapeutic categories based on requirements provided by MassHealth.

  • Anticoagulants
  • Antidiabetic agents (oral and injectable)
  • Anti-hypoglycemic agents
  • Antiretrovirals
  • Asthma and allergy monoclonal antibodies
  • BCL-2 Inhibitors
  • Bevacizumab and biosimilars
  • Cerebral stimulants and ADHD medications
  • CGRP inhibitors
  • Colony stimulating factors
  • Diabetic testing supplies
  • Erythropoiesis-stimulating agents
  • Growth hormone
  • Hemophilia agents
  • Hepatitis antiviral agents
  • Immune suppressants – topical
  • Immunomodulators
  • Insulin products
  • Kinase inhibitors
  • Long-acting injectable antipsychotics
  • MTOR kinase inhibitors for breast cancer
  • Multiple sclerosis agents
  • Opioid and alcohol treatment agents
  • Opioid dependence and reversal agents
  • Remicade and biosimilars
  • Respiratory agents
  • Spinal muscular atrophy agents
  • Trastuzumab and biosimilars
  • Tyrosine kinase inhibitors