As you may know, Tufts Health Together–MassHealth MCO Plan and ACPPs, in conjunction with the other Medicaid managed care organizations (MCOs) in the Commonwealth, 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; for medical drug benefit coverage, in some cases we utilize the Unified Formulary coverage and criteria, while in others Point32Health criteria apply.
We’re sharing some updates regarding medical drugs and the MassHealth Unified Formulary, which will apply for Tufts Health Together beginning July 31, 2023.
July 1 – 31: interim in-house MNGs for three drugs
We’ve developed in-house Tufts Health Together MNGs for the drugs Briumvi (J2399), Furoscix (J1941), and Sunlenca (J1961), which will be in effect from July 1, 2023 until July 31, 2023, at which point these MNGs will be retired and the drugs will be managed using the MassHealth Unified Formulary and will use the MassHealth Drug List for criteria. The criteria on the temporary Tufts Health Together MNGs will mirror MassHealth’s criteria.
Other MassHealth Unified Formulary updates for July 31
In addition to the three drugs referenced above, the following medical drug updates will take effect on July 31 and will be reflected in Point32Health’s Medical Necessity Guidelines for Medical Benefit Unified Formulary Drugs Requiring PA:
- Lunsumio (J9350): In-house MNG will be retired and MassHealth Drug List criteria will apply
- Lamzede (J3490): Prior authorization will be required and MassHealth Drug List criteria will apply
- Perseris (J2798): Prior authorization will no longer be required
- Apretude (J0739): Prior authorization will no longer be required
- Trogarzo (J3590): It will be required that the patient have an inadequate response or adverse reaction to one, or a contraindication to both of the following drugs in order to be covered: Rukobia and/or Sunlenca
- Leqvio (J1306): Changes related to the LDL-C range will require the patient to meet one of the following:
- an inadequate response (defined as ≥ the last 3 months) to a high intensity statin in combination with ezetimibe
- an adverse reaction or contraindication to ezetimibe and an inadequate response (defined as ≥ the last 3 months) to high intensity statin monotherapy
- an adverse reaction to one high intensity statin or contraindication to all high intensity statins
- Botox (J0585): Will be approved for myofascial pain syndrome and myofascial pelvic pain syndrome as off- label indications with criteria
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