Point32Health is incorporating a number of updates to our Medicare Advantage/Senior Products drug formularies for the 2024 plan year. These updates are summarized below, along with the Harvard Pilgrim and/or Tufts Health Plan Medicare products for which each change applies.
Drugs moving to non-covered status
Tufts Health Medicare Preferred HMO/PPO, Tufts Medicare Preferred Prescription Drug Plan, Tufts Medicare Preferred HMO Employer Group, Tufts Health Senior Care Options (SCO), Tufts Health Unify (soon to be Tufts Health One Care), Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage
Effective for fill dates on or after Jan. 1, 2024, Point32Health will no longer cover certain drugs, including drugs with interchangeable generics or therapeutic alternatives, for our Medicare Advantage/Senior Products members. Refer to this document for the list of drugs moving to non-covered status.
For members currently taking these drugs, coverage will continue without disruption through Dec. 31, 2023. If you are a prescribing provider and you wish for a member to continue taking a drug on this list, you’ll need to submit a formulary exception request.
All members currently utilizing the following select drugs will be grandfathered for 2024 to ensure that there is no member impact or disruption to their therapy.
- Jyanrque
- Taltz
- Ocaliva
- Cresemba
- Apomorphine injection
- Xywav
- Mavenclad
Drugs moving to a higher tier
Tufts Health Medicare Preferred HMO/PPO, Tufts Medicare Preferred Prescription Drug Plan, Tufts Medicare Preferred HMO Employer Group, Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage
For fill dates beginning Jan. 1, 2024, certain drugs will be moving to a higher tier for the plans indicated above. The associated list of drugs and tiers varies by product — please review the applicable list for each given product for complete information:
- Tufts Health Medicare Preferred HMO/PPO
- Tufts Medicare Preferred Prescription Drug Plan
- Harvard Pilgrim Stride
For members currently taking these drugs, their current coverage will continue unchanged through Dec. 31, 2023.
If an impacted patient cannot afford the new copay, please refer to the formulary for potential therapeutic alternatives at lower tiers. If the available alternatives are not clinically appropriate, a tier exception can be requested and will be reviewed in accordance with CMS regulations, as not all drugs are eligible for tier exceptions.
Addition of prior authorization requirements
Tufts Health Medicare Preferred HMO/PPO, Tufts Medicare Preferred Prescription Drug Plan, Tufts Medicare Preferred HMO Employer Group, Tufts Health Plan Senior Care Options, Tufts Health Unify (soon to be Tufts Health One Care), and Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage
Point32Health will require prior authorization for the glucagon-like peptide-1 (GLP-1) class of drugs for 2024, which includes Byetta, Bydureon, Ozempic, Trulicity, Mounjaro, Rybelsus, and Victoza.
Please keep in mind that the prescribing and utilization of these medications for weight loss is considered inappropriate, and is not allowed by the Centers for Medicare and Medicaid Services.
Members with a confirmed diagnosis of type 2 diabetes mellitus in Point32Health’s medical system will be grandfathered for 2024, and will not need to obtain a prior authorization. Members without this diagnosis who want to continue coverage will need to obtain a prior authorization, which will only be eligible for approval if they have a Part D covered indication.
Members who will not be grandfathered for 2024 will be notified.
Please note that Tufts Medicare Preferred Prescription Drug Plan and Tufts Medicare Preferred Employer Group members have coverage for some weight loss drugs as a supplemental benefit. Tufts Health Plan Senior Care Options and Tufts Health One Care will have weight loss drug coverage for 2024 under their Medicaid benefit.
Preferred product change for long-acting muscarinic agonists
Tufts Health Medicare Preferred HMO/PPO, Tufts Medicare Preferred Prescription Drug Plan, Tufts Medicare Preferred HMO Employer Group, Tufts Health Plan Senior Care Options, Tufts Health Unify (soon to be Tufts Health One Care), and Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage
The following changes will apply for respiratory products in the long-acting muscarinic agonists class of drugs, effective Jan. 1, 2024 for the plans listed above:
- Spiriva Handihaler and its generic are moving to non-formulary (Spiriva Handihaler may still be available, when appropriate, through the formulary exception process)
- Incruse Ellipta will be added to Tier 3 as the preferred formulary alternative (exception: it will remain Tier 1 for Tufts Health Plan Senior Care Options (SCO), as SCO has a 1-tier formulary)
- Spriva Respimat will remain on the formulary at Tier 3 for 2024 (exception: it will be Tier 1 for Tufts Health Plan Senior Care Options (SCO), as SCO has a 1-tier formulary)
- Point32Health will notify affected members and providers and provide a list of covered formulary alternatives to Spiriva Handihaler to Incruse Ellipta
Enhanced coverage for select Part D-excluded drugs
Tufts Health Medicare Preferred HMO/PPO
For fill dates beginning Jan. 1, 2024, we’re adding coverage for the following select erectile dysfunction drugs, vitamins and minerals, and cough and cold products typically excluded by Medicare Part D. (A quantity limit of 4 tabs per 30 days will be placed on erectile dysfunction drugs.)
| Drug | Tier |
| BENZONATATE CAP | 2 |
| CYANOCOBALAM INJ | 2 |
| FOLIC ACID TAB | 1 |
| HYD POL/CPM SUS | 2 |
| HYDROC/HOMAT TAB | 2 |
| PROMETH VC/ SYP CODEINE | 2 |
| PROMETH/COD SOL | 2 |
| SILDENAFIL CITRATE TAB | 2 |
| TADALAFIL TAB | 2 |
| VARDENAFIL TAB | 2 |
| VARDENAFIL TAB ODT | 2 |
| VITAMIN D CAP | 1 |
Preferred continuous glucose monitors
Tufts Health Medicare Preferred HMO/PPO, Tufts Medicare Preferred Prescription Drug Plan, Tufts Medicare Preferred HMO Employer Group, Tufts Health Plan Senior Care Options, Tufts Health Unify (soon to be Tufts Health One Care), and Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage
Freestyle and Dexcom continuous glucose monitoring products will be preferred at parity for 2024. Prior authorization will continue to be required for these products.
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