Reminder: MassHealth Unified Formulary

Effective April 1, 2023, Tufts Health Together–MassHealth MCO Plan and ACPPs, in conjunction with the other Medicaid managed care organizations (MCOs) in the Commonwealth, will be utilizing MassHealth’s Unified Formulary for pharmacy medications and for select medical benefit drugs.

For pharmacy medications
As of that date, pharmacy coverage and criteria for Tufts Health Together consequently will mirror that of MassHealth. Tufts Health Together will maintain its own coverage and policies for select scenarios as granted by MassHealth when appropriate, including but not limited to, quantity limit exceptions. Please note that MassHealth will be updating its opioid management strategy in April to require prior authorization of opioid regimens exceeding 180 milligram of morphine equivalents (MME) per day when two or more opioids are prescribed. Members and providers are encouraged to review the MassHealth Drug List for pharmacy drug coverage and criteria.

For medical benefit drugs
For medical drug benefit coverage, in some cases we will utilize the MassHealth Drug List criteria, while in others Point32Health criteria will apply. In addition, we are removed prior authorization from some medical benefit drugs for Tufts Health Together members.

Prior authorization no longer required — The following medical benefit drugs and codes will be covered without prior authorization for Tufts Health Together members, effective April 1, 2023.

Newly require prior authorization and will utilize MassHealth Drug List criteria — Beginning April 1, 2023, for coverage for Tufts Health Together Members, the following medical benefit drugs and codes will require prior authorization and must meet the criteria of the MassHealth Drug List.

Will continue to require prior authorizations and will use MassHealth Drug List criteria — The following drugs currently require prior authorization for Tufts Health Together members and will continue to do so. As of April 1, 2023, coverage criteria used will be MassHealth’s Drug List criteria.

No change — Continue to require prior authorization and must meet criteria in Tufts Health Plan’s medical necessity guidelines.

For more information on medical benefit drug coverage for Tufts Health Together members, please refer to the MassHealth Medical Benefit Unified Formulary Drugs Requiring PA Medical Necessity Guideline, as well as the MassHealth Drug List.

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