Point32Health is incorporating a number of updates to our Tufts Health Plan Senior Products drug formularies for the 2025 plan year. These updates are summarized below, along with the Medicare products for which each change applies.
1. Drugs moving to non-covered status
Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Effective for fill dates on or after Jan. 1, 2025, we will no longer cover certain drugs, including drugs with interchangeable generics or therapeutic alternatives, for members of the plans indicated above. Refer to this document (pages 1-2) for the list of drugs moving to non-covered status.
For members currently taking these drugs, coverage will continue without disruption through Dec. 31, 2024. 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.
2. Drugs moving to a higher tier
Tufts Medicare Preferred
For fill dates on or after Jan. 1, 2025, certain drugs will be moving to a higher tier for Tufts Medicare Preferred members only. Click here to review a list of these drugs, which you’ll find on pages 2-5.
For members currently taking these drugs, their current coverage will continue unchanged through Dec. 31, 2024.
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.
Please keep in mind that for 2025, certain provisions of the Inflation Reduction Act may help manage costs for eligible patients impacted by these formulary changes, including the lowering of the out-of-pocket maximum to $2,000 and the availability of a Medicare Prescription Payment Plan, which allows patients to spread costs for Medicare Part D prescription drugs out by splitting bills into monthly installments across the calendar year.
3. New prior authorization and step therapy requirements
Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
For the 2025 plan year, Point32Health will require prior authorization for alosetron, indicated for the treatment of irritable bowel syndrome in women, for Senior Products plans. Additionally, we are adding a step therapy requirement for the medication Rebif; members will be required to have first tried at least two of our preferred products for multiple sclerosis (Avonex, Betaseron, or Plegridy) before coverage will be available for Rebif.
4. Respiratory preferred product change for ICS-LABA class
Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Effective for fill dates on or after Jan. 1, 2025, the authorized generic for Symbicort (budesonide/formoterol) will be moving to non-covered status. Breo Ellipta will remain our preferred product for this drug class, and Breyna (true generic for Symbicort) will move from Tier 3 to Tier 4.
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