Pharmacy Coverage Changes

Tufts Medicare Preferrerd HMO, Tufts Medicare Preferred PDP, Tufts Health Plan SCO, Tufts Health Unify

November 01, 2021  

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:

Drug Class Non-preferred Product(s) Preferred Product(s)
Autoimmune Avsola
Renflexis
Inflectra
Remicade
Bendamustine HCI Injection Treanda Bendeka
Belrapzo
Bevacizumab – Oncology Avastin Mvasi
Zirabev
Iron Preparation, Parenteral Feraheme
Injectafer
Monoferric
Ferrlecit
Infed
Venofer
Leucovorin/LEVOleucovorin Injection Fusilev
Khapzory
leucovorin injection
Neutropenia Colony Stimulating Agents – long acting Nyvepria
Udenyca
Ziextenzo
Fulphila
Neulasta
Neutropenia Colony Stimulating Agents – short acting Granix
Leukine
Neupogen
Nivestym
Zarxio
Paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome Soliris Ultomiris
Retinal Disorders Beovu
Eylea
Lucentis
Macugen
Visudyne
Avastin
Myasi
Zirabev
Rituximab Rituxan
Rituxan Hycela
Riabni
Ruxience
Truxima
Trastuzumab Herceptin
Herceptin Hylecta
Herzuma
Kanjinti
Ogivri
Ontruzant
Trazimera
Triamcinolone Acetonide Injection Zilretta triamcinolone acetonide injection
Viscosupplements Durolane
Gel-One
Gel-Syn
Genvisc 850
Hyalgan
Hymovis
Monovisc
Orthovisc
Supartz
Synojoynt
Synvisc
Synvisc One
Triluron
Trivisc
Visco-3
Euflexxa

Noncovered Drugs

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.