Point32Health would like to offer a number of reminders pertaining to our Pharmacy program.
FDA-unapproved product coverage
Tufts Health Plan commercial, Tufts Health Direct, Harvard Pilgrim Health Care commercial
As a reminder, any products not listed on the Harvard Pilgrim commercial, Tufts Health Plan commercial, and Tufts Health Direct formularies that have not been approved by the FDA are excluded from coverage, in alignment with the information listed on our Evidence of Coverage documents and Member Handbooks. Before prescribing any medication to a Point32Health member, please be sure to always refer to the member’s formulary to verify that the medication is listed as covered.
Prenatal vitamin coverage
Tufts Health Plan commercial, Tufts Health Direct, Harvard Pilgrim Health Care commercial
Effective for fill dates on or after Jan. 1, 2024, Harvard Pilgrim commercial, Tufts Health Plan commercial, and Tufts Health Plan Direct will only cover prescription generic prenatal vitamins on our pharmacy formulary. Brand and generic over-the-counter prenatal vitamins will be excluded. All brand prescription prenatal vitamins will be moved to non-formulary. Please refer to the formulary for information on prenatal vitamins. You can find formulary information on the pharmacy pages of the Harvard Pilgrim and Tufts Health Plan provider websites. To request that a patient continue to receive coverage for a non-formulary prenatal vitamin, the prescribing provider must request an exception through the pharmacy review process under the Pharmacy Medical Necessity Guidelines for Non-Formulary Exceptions policy (Harvard Pilgrim, Tufts Health Plan).
Basal insulins coverage
Tufts Health RITogether
As we outlined in last month’s issue of Insights and Updates for Providers, effective Jan. 1, 2024 for Tufts Health RITogether, Basaglar (insulin glargine) KwikPen will be moved to noncovered status. Prior authorization will be required for new and existing utilizers. As of the Jan. 1 effective date, insulin glargine-yfgn vial and pen will be covered without prior authorization. Please keep in mind that insulin glargine-yfgn is not interchangeable with Basaglar KwikPen at the pharmacy, and therefore a new prescription will be required.
Reminder: Inhaled Corticosteroid Inhalers
Tufts Health Together
As previously communicated, brand name Flovent HFA (fluticasone propionate) and Flovent Diskus will be discontinued at the end of 2023, and MassHealth will consequently be making coverage updates in the inhaled corticosteroid inhaler class as part of the December rollout (effective Dec. 4, 2023):
- Brand Flovent HFA and Flovent Diskus will continue to be covered without prior authorization. Members can fill brand Flovent HFA and brand Flovent Diskus until the supply runs out.
- Generic Flovent HFA and generic Flovent Diskus will not be preferred and will require prior authorization.
- Approval criteria for generic Flovent will require documentation of an asthma diagnosis and trial and failure with at least two inhaled corticosteroids available without prior authorization.
- Arnuity Ellipta (fluticasone furoate inhalation powder) will no longer require prior authorization. Asmanex HFA (mometasone inhalation aerosol), Asamanex Twisthaler (mometasone inhalation powder) and Pulmicort Flexhaler (budesonide inhalation powder) will continue to be covered without prior authorization.
Members already stable on brand Flovent inhalers may use generic fluticasone inhalers until March 4, 2024 to allow for a transition period while they are switched to another inhaler. After that time prior authorization for generic fluticasone inhalers will be required for everyone.
Reminder: preferred continuous glucose monitors
Tufts Health Direct
As a reminder, all FreeStyle Libre flash continuous glucose monitors (CGMs) and their accompanying supplies are preferred for Tufts Health Direct members and covered with prior authorization. They are available through the pharmacy only when the member has a prescription through the pharmacy benefit. (As of Jan. 1, 2023, Dexcom G6 CGMs are no longer preferred products.)
FreeStyle Libre and its supplies require prior authorization and are reviewed against criteria in the Pharmacy Medical Necessity Guideline for Insulin and Diabetes Supplies. Dexcom G4®, Dexcom G5®, Dexcom G6 and Medtronic Guardian™ are non-formulary. For a member to continue using any of these nonformulary products, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Non-Formulary Exceptions. Should a request for any of these products be approved, members will have to fill their CGM and its supplies at the pharmacy, as they are unavailable through the DME supplier. All CGMs are restricted with quantity limitations. For these requests, the prescribing provider must request coverage through the medical review process subject to the applicable pharmacy medical necessity guidelines via the Pharmacy Utilization Management Department fax at 617-673-0988.
Audrey Kleinberg,
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