Pharmacy Coverage Changes – Commercial

Commercial (including Tufts Health Freedom Plan)

October 31, 2018  

The following changes apply to Commercial products (including Tufts Health Freedom Plan):

Long-Acting Colony Stimulating Factors

Effective for fill dates on and after September 24, 2018, Tufts Health Plan now covers Fulphila™ (pegfilgrastim-jmdb) as an alternative to Neulasta® (pegfilgrastim). Fulphila (pegfilgrastim-jmdb) will have the same coverage as Neulasta (pegfilgrastim). Both agents will require prior authorization through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Pegfilgrastim Products (Fulphila™, Neulasta®).

Prior Authorization

Submitting Prior Authorization Requests to Tufts Health Plan
For information on which form to use when submitting a prior authorization request to Tufts Health Plan, refer to Commercial Pharmacy Medication Prior Authorization Submission by State.

Changes to Existing Prior Authorization Programs
Effective for prior authorization requests submitted on or after January 1, 2019, Tufts Health Plan will update its prior authorization criteria for anti-inflammatory conditionsantidepressant medicationsinsomnia treatments and respiratory interleukins. 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.

New Prior Authorization Program
Effective for fill dates on or after January 1, 2019, Tufts Health Plan will require prior authorization for coverage of Belbuca™ (buprenorphine) buccal film, buprenorphine transdermal patch, H.P. Acthar® (corticotropin) and all multisource brand hormonal contraceptives. These changes will apply to members currently utilizing one of these medications as well as members initiating a new course of treatmentFor these requests, the prescribing provider must request coverage through the medical review process subject to the applicable pharmacy medical necessity guidelines.

Note: Coverage of H.P. Acthar (corticotropin) will be authorized only under the pharmacy benefit.

Specialty Pharmacy Program

Effective for fill dates on or after January 1, 2019, Tufts Health Plan will add Coagadex® (coagulation Factor X [Human]), H.P. Acthar® (corticotropin), Kanuma® (sebelipase alfa) and Zydelig® (idelalisib) to its specialty pharmacy program provided by CVS Specialty.

Tier Changes

Tufts Health Plan will implement tier changes for the following drugs effective for fill dates on or after January 1, 2019:

Drugs Moving to Tier 1

  • lovastatin tablets

Drugs Moving to Tier 2

  • amphetamine-dextroamphetamine ER capsules
  • clomipramine 25mg, 50mg and 75mg capsules
  • clonidine ER tablets
  • desipramine 10mg, 25mg, 50mg, 75mg, 100mg and 150mg tablets
  • dextroamphetamine ER capsules
  • imipramine pamoate 100mg and 150mg capsules
  • methylphenidate CD capsules
  • methylphenidate ER capsules
  • methylphenidate ER solution
  • methylphenidate ER tablets
  • nefazodone 50mg, 100mg, 150mg, 200mg and 250mg tablets
  • paroxetine ER 12.5mg, 25mg and 37.5mg tablets
  • tranylcypromine 10mg tablets

Drugs Moving to Tier 3

  • methamphetamine tablets
  • trimipramine 25mg and 100mg capsules
  • venlafaxine 225mg ER tablets

Quantity Limitations

Effective for fill dates on or after January 1, 2019, Tufts Health Plan will add quantity limitations to all immediate-release opioid combination analgesic products containing opioids, acetaminophen, aspirin and ibuprofen. These added quantity limits are in line with FDA-approved prescribing limits for short-acting opioid combination products, limiting the maximum daily dose of each of the following to these amounts: 90 morphine milligram equivalent (MME) of immediate-release opioid, 4g acetaminophen or aspirin, or 3,200mg ibuprofen.

The quantity limitations will apply to patients currently taking any of these medications, as well as to patients initiating a new course of treatment. In order for a member to receive coverage for quantities above the FDA-approved daily limits, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Drugs With Quantity Limitations.

Vivotif® Oral Typhoid Vaccine

Effective for fill dates on or after January 1, 2019, Tufts Health Plan will open access to Vivotif, the oral typhoid vaccine, at retail pharmacies. This change will allow members to fill a prescription for Vivotif at a retail pharmacy at no cost share.

Note: Despite Vivotif being available at retail pharmacies, the oral vaccine will be covered under members’ medical benefit and not the pharmacy benefit.

Drugs Moving to Noncovered Status

Tufts Health Plan will move the following drugs to noncovered status effective for fill dates on or after January 1, 2019:

  • duloxetine 40mg DR capsules
  • fluoxetine weekly 90mg capsules
  • fluvoxamine ER 100mg and 150mg capsules
  • Invokamet®
  • Invokamet® XR
  • Invokana®
  • isotretinoin capsules
  • Jentadueto®
  • Jentadueto® XR
  • Metrogel® 1% gel
  • Otrexup®
  • Praluent®
  • Proventil® HFA
  • Relistor®
  • Surmontil® 25mg, 50mg and 100mg capsules
  • Symproic®
  • Tradjenta®
  • venlafaxine ER 37.5mg, 75mg and 150mg tablets
  • Ventolin® HFA

For a member to continue taking any of the above medications, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Noncovered Drugs With Suggested Alternatives.

Drugs Moving to Excluded Status

Tufts Health Plan will move the following drugs to excluded status effective for fill dates on or after January 1, 2019:

  • Over-the-counter vitamin D supplements
  • Prevident® 5000 fluoride toothpaste
  • Renova® cream

Inhaler Coverage

Effective for fill dates on or after January 1, 2019, Tufts Health Plan will offer coverage for asthma and COPD inhalers as indicated in the Review of Inhaler Coverage grid.

Note: Coverage varies by product and is indicated in the Review of Inhaler Coverage grid.

Large Groups

The following changes apply to large-group Commercial formularies and are effective for fill dates on or after January 1, 2019:

Drugs Moving to Tier 3

  • Ampyra®

Drugs Moving to Noncovered Status

  • Butrans® Transdermal System
  • Clindagel® 1% gel
  • Dexpak® Dose Pak
  • Eurax® 10% lotion
  • Intermezzo® sublingual tablets
  • Lunesta® tablets
  • Sporanox® solution
  • Uceris® 9mg tablets
  • Welchol® 3.7gm Powder Packet
  • Xopenex® HFA
  • Zyclara® Pump 3.75% cream

For a member to continue taking any of the above medications, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Noncovered Drugs With Suggested Alternatives.