MassHealth recently announced the following updates to the MassHealth Unified Formulary, effective Oct. 2, 2023. The table below outlines these changes, which include pharmacy products and medical drugs being added to the MassHealth Drug List, as well as new and updated prior authorization programs.
As we noted previously, Tufts Health Together-MassHealth MCO Plan and ACPPs, in conjunction with the other managed care organizations (MCOs) in the Commonwealth, began utilizing MassHealth’s Unified Formulary for pharmacy medications and select medical benefit drugs as of April 1, 2023. Consequently, the pharmacy coverage and criteria for Tufts Health Together mirror that of MassHealth.
Please keep in mind that updated coverage and criteria will be available on the MassHealth Drug List on or after the effective date.
| Adding prior authorization | Abilify Asimtufii; Allopurinol 200 mg tablet; Cuvrior; Leqembi; Omnipod Go; OTC ivermectin lotion; Vowst |
| Existing medical benefit prior authorization will now utilize MassHealth criteria | Syfovre |
| Therapeutic class tables being updated | Agents Not Otherwise Classified; Alzheimer’s Agents; Antipsychotics; Barbituates, Benzodiazepines, and Miscellaneous Anti-Anxiety Agents; Beta Thalassemia, Myelodysplastic Syndrome, and Sickle Cell Disease Agents; Corticosteroids – Intranasal; Diabetes Medical Supplies and Emergency Treatments; Gout Agents; Immunological Agents; Muscle Relaxants – Skeletal; Multiple Sclerosis Agents; Oncology Agents; Opioids and Analgesics*; Palivizumab (Synagis); Pediatric Behavioral Health; Pediculicides and Scabicides; Pharmaceutical Compounds; T-Cell Immunotherapies |
| Drugs being removed from the MassHealth brand name preferred over generic list | Invega tablet |
| Drugs being locked to the medical benefit (utilization management restrictions may apply) | Enjaymo, Padcev, Soliris, Syfovre, Uplizna, Vyvgart |
| Removing from MassHealth Drug list due to product discontinuation | Ivermectin lotion (Rx), Sklice lotion (ivermectin) (Rx) |
| Compounding program updates | Compounded products meeting any of the following parameters will require PA: $100 or greater total allowed ingredient cost; topical route of administration; any active ingredient requiring prior authorization
The following compounding ingredients will be moved to not covered: benzodiazepine powders (alprazolam, clonazepam, diazepam, lorazepam, midazolam); cocaine crystals, powder; methylphenidate powder; opioid powders (apomorphine, buprenorphine, cocaine, codeine, fentanyl, hydrocodone, hydromorphone, levorphanol, methadone, morphine sulfate, oxycodone, sufentanil); PCCA compounding ingredients (including, but not limited to, proprietary bases, active pharmaceutical ingredients, and excipients) |
| Drugs being mandated to a 90-day supply after an initial fill | Alfuzosin extended-release; Timoptic Ocudose; Zioptan |
*Tufts Health Plan maintains its own Opioids and Analgesics Pharmacy Medical Necessity Guidelines, which will be updated prior to Oct. 2, 2023 to align criteria with the MassHealth Unified criteria. Please refer to this policy for more information.
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