Back to Insights and Updates for ProvidersJune 2023

MassHealth Unified Formulary: medical drug updates

Tufts Health Together

As a reminder, Tufts Health Together–MassHealth MCO Plan and ACPPs, in conjunction with the other Medicaid managed care organizations (MCOs) in the Commonwealth, now utilize MassHealth’s Unified Formulary for pharmacy medications and for select medical benefit drugs.

Pharmacy coverage and criteria for Tufts Health Together consequently mirror that of MassHealth — but for medical drug benefit coverage, in some cases we utilize the Unified Formulary coverage and criteria, while in others Point32Health criteria apply.

Effective for dates of service beginning June 5, 2023, a number of updates regarding medical drugs and the MassHealth Unified Formulary will apply for Tufts Health Together.

Rebyota (J3590) will require prior authorization and will use the MassHealth Drug List for criteria, and the following Point32Health Medical Necessity Guidelines for Tufts Health Together will be retired and these medical drugs will also use MassHealth Drug List criteria:

  • Tzeild (C9148)
  • Tecvayli (C9149)
  • Xenpozyme (J0218)
  • Zynteglo (J3490)

(For a full list of medial benefit drugs that use the MassHealth Drug List for criteria for Tufts Health Together, please refer to our Medical Benefit Unified Formulary Drugs Requiring PA MNG.)

The following off-label uses have been added to the MassHealth Drug List with criteria and will now be covered indications for all intravenous immune globulin (IVIG) products:

  • Antibody mediated rejection (AMR)
  • Immune mediated necrotizing myopathy (IMNM)
  • Intestinal Lung Disease (ILD)
  • Pemphigus Vulgaris (PV)
  • Polymyositis (PM)
  • Prevention of recurrent infection in pediatric HIV members

For all off-label uses for IVIG products, initial authorizations will now be for three months, and reauthorizations will be for six months.

Authorizations for Oxlumo (J0224) will now be approved for one year, as opposed to the previous timeframe of six months.
Aveed (J3145) and Testopel (S0189) will now be approved for gender identity disorder/gender dysphoria/ transsexualism/therapy after gender reassignment surgery under the MassHealth Drug List.
Quzyttir (J3490) will be locked to the medical benefit.
Minor updates will be made to the criteria for the following drugs:

  • Abilify Maintena (J0401)
  • Perseris (J2798)
  • Trogarzo (J3590)
  • Nucala (J2182)
  • Reblozyl (J0896)
  • Aranesp (J0881)
  • Epogen (J0885)
  • Procrit (J0885)
  • Retacrit (Q5106)
  • Lemtrada (J0202)
  • Remodulin (J3285)
  • Veletri (J1325)

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