Pharmacy Coverage Changes

Tufts Health RITogether, Tufts Health Together

November 01, 2021  

Prior Authorization

New Prior Authorization Programs
Antidiabetic Agents: Tufts Health Together – MassHealth MCO Plan and ACPPs
Effective for fill dates on or after January 1, 2022, Tufts Health Plan will implement the following coverage changes for antidiabetic agents as part of the MassHealth MCO/ACPPs Unified Pharmacy Product List (UPPL):

Medication Name Current Coverage Coverage Effective 1/1/2022
Adlyxin (lixisenatide) Not Covered PA, QL
Alogliptin (generic Nesina)
Alogliptin/metformin (generic Kazano)
Alogliptin/pioglitazone (generic Oseni
PA, QL, 90 DS Not Covered, QL
Duetact (pioglitazone/glimepiride)
Glumetza (metformin ER gastric tablet)
Not Covered PA, QL, Brand Preferred
PA, Brand Preferred
Kazano (alogliptin/metformin)
Nesina (alogliptin)
Oseni (alogliptin/pioglitazone)
Not Covered, QL PA, QL, Brand Preferred
Metformin ER gastric tablet (generic Glumetza) PA, 90 DS Not Covered
Pioglitazone/glimepiride (generic Duetact) Covered, 90 DS Not Covered, QL
Qtern (dapagliflozin/saxagliptin) Not Covered PA, QL
Repaglinide/metformin Covered, 90 DS PA, QL, 90 DS
Steglujan (ertugliflozin/sitagliptin)
Trijardy XR (empagliflozin/linagliptin/metformin ER )
Not Covered PA, QL

90 DS = drug is available for a 90-day supply; ER = extended-release; PA = Prior Authorization required, QL = quantity limi

Current utilizers of Adlyxin, Duetact, pioglitazone/glimepiride, Qtern, repaglinide/metformin, Steglujan and Trijardy XR will not be grandfathered. For requests for impacted agents (except generic pioglitazone/glimepiride), the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Non-Insulin Antidiabetic Agents. For requests for generic pioglitazone/glimepiride, the prescription provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Non-Covered Pharmacy Products.

Additionally, members currently taking generic alogliptin (Nesina), alogliptin/metformin (Kazano), alogliptin/pioglitazone (Oseni), and metformin extended-release gastric tablet (Glumetza) should switch to the equivalent brand formulation on or after January 1, 2022. For a member to fill the generic formulations of these medications, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Non-Covered Pharmacy Products.

For a member to receive coverage for quantities above the new quantity limits, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Products with Quantity Limitations. Note: The following agents will no longer be included in Tufts Health Together – MassHealth MCO Plan and ACPPs’ voluntary 90-day supply pharmacy program:

  • Alogliptin
  • alogliptin/metformin
  • alogliptin/pioglitazone
  • metformin ER gastric tablet
  • pioglitazone/glimepiride

Respiratory Agents: Tufts Health Together – MassHealth MCO Plan and ACPPs
Effective for fill dates on or after January 1, 2022, Tufts Health plan will implement the following coverage changes for respiratory inhalers as part of the MassHealth MCO/ACPPs UPPL:

Medication Name Current Coverage Coverage Effective 1/1/2022
AirDuo Digihaler Not Covered PA, QL
Armonair Digihaler(fluticasone inhalation powder) Not Covered PA
ProAir Respiclick(albuterol inhalation powder) Covered PA

PA = Prior Authorization required; QL = quantity limit

Note: Current utilizers of Airduo Digihaler, Armonair Digihaler and Proair Respiclick will not be grandfathered. For these requests, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Respiratory Inhalers. For a member to receive coverage for quantities above the new quantity limits, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Products with Quantity Limitations.

Xifaxan (rifaximin) 550 mg tablet: Tufts Health Together – MassHealth MCO Plan and ACPPs
Effective for fill dates on or after January 1, 2022, Tufts Health Plan will require prior authorization for coverage of Xifaxan (rifaximin) 550 mg tablet. This coverage change applies to members currently taking Xifaxan 550 mg tablet as well as those initiating a new course of treatment. For these requests, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Xifaxan 550 milligram tablet.

Changes to Existing Prior Authorization Programs
Effective for prior authorization requests submitted on or after January 1, 2022, 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:

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

  • Anticonvulsants/Mood Stabilizers
  • Antipsychotic Medications
  • Complement Inhibitors
  • Cushing’s Disease Agents
  • Dificid® (fidaxomicin)
  • Gastrointestinal Medications
  • Evkeeza™ (evinacumab-dgnb)
  • Savella® (milnacipran)

Tufts Health Together – MassHealth MCO Plan and ACPPs

  • ADHD CNS Stimulant Medications
  • Amyloidosis Therapies
  • Anticoagulants
  • Buprenorphine/Naloxone Medications (Bunavail™, buprenorphine/naloxone tablets, Zubsolv®)
  • Buprenorphine Sublingual Tablets
  • Continuous Glucose Monitoring Systems – Dexcom G6 and FreeStyle Libre Systems Only
  • Cosela™ (trilaciclib)
  • Growth Hormone Replacement Therapy
  • Multiple Sclerosis Agents
  • Non-Insulin Antidiabetic Agents
  • Oral Cancer Medications
  • Products with Quantity Limitations
  • Respiratory Inhalers
  • Targeted Immunomodulators – Biological Agents
  • Xifaxan® 550 milligram tablet
  • Zeposia® (ozanimod)

Tufts Health RITogether

  • Hypnotic Agents
  • Migraine Medications: Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists, Serotonin (5-HT) 1F Receptor Agonists and Triptans

Quantity Limitations
Effective for fill dates on or after January 1, 2022, Tufts Health Plan will update its quantity limitations for the medications listed below. For a member to receive coverage for quantities above the new quantity limits, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Products with Quantity Limitations for Tufts Health RITogether and Tufts Health Together – MassHealth MCO Plan and ACPPs.

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

  • Dificid® (fidaxomicin) suspension
  • Nayzilam® (midazolam) nasal solution
  • Savella® (milnacipran) titration pack
  • Secuado® (asenapine) transdermal patch

Tufts Health RITogether

  • Baqsimi® (glucagon) nasal powder
  • Belsomra® (suvorexant) tablet
  • DayVigo® ( emborexant) tablet
  • Glucagon injection
  • GlucaGen® HypoKit® (glucagon) injection
  • Gvoke® HypoPen® (glucagon injection)
  • Gvoke (glucagon) prefilled syringe

Tufts Health Together – MassHealth MCO Plan and ACPPs

  • Adlyxin® (lixisenatide) injection
  • AirDuo® Digihaler® (fluticasone/salmeterol inhalation powder)
  • Azstarys™ (serdexmethylphenidate/dexmethylphenidate) capsule
  • Bunavail® (buprenorphine/naloxone) buccal film
  • Buprenorphine sublingual tablet
  • Buprenorphine/naloxone sublingual tablet
  • Duetact® (pioglitazone/glimepiride) tablet
  • Jornay PM® (methylphenidate extended-release) capsule
  • Pioglitazone/glimepiride tablet
  • Qtern® (dapagliflozin/saxagliptin) tablet
  • Repaglinide/metformin tablet
  • Steglujan™ (ertugliflozin/sitagliptin) tablet
  • Trijardy XR® (empagliflozin/linagliptin/metformin extended-release) tablet
  • Zubsolv® (buprenorphine/naloxone) sublingual tablet

Drugs Status Changes

Drugs Moving to Noncovered Status
Effective for fill dates on or after January 1, 2022, Aimovig® (erenumab-aooe) will be moved to noncovered status for Tufts Health RITogether. For a member to continue taking Aimovig, 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.

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. This form can be faxed or mailed to Tufts Health Plan’s Pharmacy Utilization Management Department, as indicated on the form.

Note: Effective for dates of service on or after January 1, 2022, Emgality® (galcanezumab-gnlm) 120 mg/mL will be covered with prior authorization and quantity limitations.

Coverage of Select Drugs Requiring Skilled Administration

Effective for fill dates on or after January 1, 2022 for Tufts Health Together – MassHealth MCO Plan and ACPPs, the following medications will be excluded from the pharmacy benefit. Note: These medications will continue to be covered on the medical benefit with no change to current utilization management requirements. As January 1, 2022, providers should “buy and bill” these medications directly by purchasing the drug from the distributor, stocking it in their clinic or office and then billing Tufts Health Plan for the cost of the drug and the administration costs after administering to the member.