Pharmacy Coverage Changes
Tufts Medicare Preferrerd HMO, Tufts Medicare Preferred PDP, Tufts Health Plan SCO, Tufts Health Unify
Medicare Part B Step Therapy Policy
Effective for dates of service on or after January 1, 2022, Tufts Health Plan will implement a Medicare Part B Step Therapy Policy, which will require members to first try certain preferred drugs to treat their medical condition before coverage of another non-preferred drug for that condition is approved as medically necessary by Tufts Health Plan. These coverage changes only apply to Tufts Medicare Preferred HMO, Tufts Health Plan Senior Care Options (SCO) and Tufts Health Unify members initiating a new course of treatment. For these requests, the prescribing provider must request coverage through the medical review process subject to the Medicare Part B Step Therapy Policy. Note: This change does not apply to Tufts Medicare Preferred HMO Employer Groups.
The policy applies a step therapy for the following drugs:
|Bendamustine HCI Injection
|Bevacizumab – Oncology
|Iron Preparation, Parenteral
|Neutropenia Colony Stimulating Agents – long acting
|Neutropenia Colony Stimulating Agents – short acting
|Paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome
|Triamcinolone Acetonide Injection
||triamcinolone acetonide injection
Effective for fill dates on or after January 1, 2022, Tufts Health Plan will no longer cover several drugs, including drugs with interchangeable generics or therapeutic alternatives, for Tufts Medicare Preferred HMO, Tufts Medicare Preferred PDP, Tufts Health Plan SCO and Tufts Health Unify. For members currently taking these drugs, coverage will continue without disruption through December 31, 2021. For a member to continue taking one of these noncovered drugs, the prescribing provider must submit a formulary exception request.
Drug Status Changes
Effective for fill dates on or after January 1, 2022, several drugs will be moving tiers for Tufts Medicare Preferred HMO and Tufts Medicare Preferred PDP. For members currently taking these drugs, coverage will continue without disruption through December 31, 2021. If a member cannot afford the new copayment, refer to the formulary for potential therapeutic alternatives at lower tiers. If the available alternatives are not clinically appropriate, a tier exception can be requested and will be reviewed in accordance with CMS regulations, as not all drugs are eligible for tier exceptions.