Back to Insights and Updates for ProvidersNovember 2023

Pharmacy coverage changes

Harvard Pilgrim Health Care Commercial  |  Tufts Health Direct  |  Tufts Health Plan Commercial  |  Tufts Health RITogether

Quantity limitations

Effective for fill dates on or after Jan. 1, 2024, Harvard Pilgrim commercial, Tufts Health Plan commercial, and Tufts Health Direct formularies will have new or updated quantity limitations for the following medications. For a member to receive coverage for quantities above the new or updated limit, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Drugs with Quantity Limitations.

Anti-emetics (i.e., aprepitant, Akynzeo, scopolamine transdermal patch, Sancuso, Varubi) GLP-1 agonists (i.e., Ozempic, Saxenda)
Anti-infectives and antivirals (i.e., Coartem, oseltamivir capsule and suspension, Relenza Diskhaler, Sitavig, Sivextro, Xifaxan 200mg and 550mg) Long-acting colony stimulating factors (e.g., Neulasta)
Breztri Aerosphere Long-acting stimulants (e.g., amphetamine-dextroamphetamine extended-release)
Diabetes supplies (i.e., Freestyle Libre 14 day sensors, Freestyle Libre 2 sensors, and Freestyle Libre 3 sensors, On Call Express blood glucose test strips) Pirfenidone
Epinephrine autoinjectors Radicava ORS
Evrysdi Triptans (e.g., sumatriptan)

Drug status changes

The following changes apply to Harvard Pilgrim commercial products, Tufts Health Plan commercial products, and Tufts Health Direct, and are effective for fill dates on or after Jan. 1, 2024:

Drugs moving to non-formulary status

Drug name  Impacted formularies
ProAir Respiclick
Ventolin HFA
Flovent HFA & Flovent Diskus
Advair Diskus
Bonjesta
Doryx MPC 120mg
Relistor injection
Amitiza
Bevespi Aerosphere
Utibron Neohaler
Clobetasol 0.05% emulsion foam
Clocortolone 0.1% cream
Desonide 0.05% gel
Desoximetasone 0.05% cream, gel, ointment
Diflorasone 0.05% cream, emollient cream (Apexicon E), ointment
Fluocinolone 0.01% and 0.025% cream
Flurandrenolide 0.05% cream, lotion, ointment, 4mcg/cm tape (Cordran)
Fluticasone 0.05% lotion
Halcinonide 0.1% cream
Hydrocortisone 2% lotion (Ala-Scalp)
Hydrocortisone 2.5% solution (Texacort)
Prednicarbate 0.1% cream
Triamcinolone 0.05% ointment
azathioprine 75mg and 100mg
Diclofenac 25mg tablet
Value, Premium, CoreNH, and Direct
Trulance
Lupron Depot
Amcinonide 0.1% cream, lotion, ointment
Hydrocortisone butyrate 0.1% cream, lotion, lipo base cream, ointment, solution
Value, Premium, and Direct
Relistor tablet
Ultravate 0.05% lotion
Pandel 0.1% cream
Hydrocortisone butyrate 0.1% lotion
Epifoam
Enstilar
Premium
Plegridy
Rebif
Amcinonide 0.1% lotion, ointment
Hydrocortisone butyrate 0.1% lotion, lipo base cream, ointment, solution
CoreNH

Multisource brands moving to non-formulary status
Drug name Impacted formularies
Aczone Gel
Alphagan P 0.1% solution
Amitiza
Azasan
Bidil
Chantix tablets and packs
Cytomel
Daliresp
Daytrana patches
Denavir cream
Depakote Sprinkle capsules and ER tablets
Dilantin chewable tablets, capsules, and suspension
Divigel
Epipen and Epipen-JR injection
Esbriet capsule and tablets
Ferriprox tablets
Gilenya
Glucagon Kit 1mg
Hetlioz capsules
Iressa
Lanoxin tablets
Latuda
Mirvaso gel
Naprelan CR
Nexavar tablets
Noxafil suspension and packet
Pentasa CR
Suprep Bowel Sol Prep Kit
Targretin gel
Tazorac gel
Toviaz
Vascepa
Viibryd tablets
Vimpat solution
Zenzedi
Zioptan drops
Value, Premium, CoreNH, and Direct
Aubagio Value, Premium, and Direct

Drugs moving to higher tier
Drug name
Impacted formularies
Aprepitant capsules and packet
Griseofulvin tab and suspension
Alclometasone 0.05% cream, ointment
Betamethasone dipropionate augmented 0.05% gel, ointment
Betamethasone valerate 0.1% lotion
Desoximetasone 0.25% spray
Fluocinolone 0.025% ointment
Fluocinonide 0.05% emulsified cream
Halobetasol 0.05% cream
Prednicarbate 0.1% ointment
Betamethasone dipropionate 0.05% ointment
Betamethasone valerate 0.12% foam
Clobetasol 0.05% cream (emollient), lotion, shampoo, spray
Desonide 0.05% cream, lotion
Hydrocortisone valerate 0.2% ointment
Triamcinolone 0.147 mg/g spray
Value, Premium, CoreNH, and Direct
Calcipotriene-betamethasone dipropionate ointment 0.005-0.064% Premium
Amcinonide 0.1% cream
Hydrocortisone butyrate 0.1% cream
CoreNH

Drugs moving to excluded status
Drug name Impacted formularies
Urea cream 39%
Urea lotion 40%
Urea cream 41%
Sulfacetamide sodium w/ sulfur 10-5% suspension
Sulfacetamide sodium w/ sulfur 10-5% lotion
Selenium sulfide 2.25% shampoo
Value, Premium, CoreNH, and Direct
Pramosone 2.5% ointment Premium

Changes to existing prior authorization programs

Updates to existing prior authorization programs
Drug Plan Eff. date Policy & additional information
Adhansia XR, Dexmethylphenidate ER, Dynavel XR oral solution/chewable tablet, Evekeo ODT, lisdexamfetamine capsule, methylphenidate ER (Ritalin LA) 10 mg and 60 mg capsule, methylphenidate transdermal, Quillivant XR, Tufts Health RITogether Jan. 1, 2024 CNS Stimulant Medications
Quantity Limit Exceptions Harvard Pilgrim Health Care commercial, Tufts Health Plan commercial, Tufts Health Direct Jan. 1, 2024 Quantity Limit Exceptions (Harvard Pilgrim, Tufts Health Plan)
Armodafinil, Modafinil Tufts Health RITogether Jan. 1, 2024 Analeptic CNS Stimulants: Armodafinil and Modafinil
Asmanex HFA
Asmanex Twisthaler
Harvard Pilgrim Health Care commercial, Tufts Health Plan commercial, Tufts Health Direct Jan. 1, 2024 Asmanex Step Therapy (Harvard Pilgrim, Tufts Health Plan)
Auvelity, desvenlafaxine, Drizalma, Emsam, Fetzima, fluoxetine tablet, fluvoxamine ER capsule, imipramine pamoate, olanzapine/ fluoxetine, paroxetine 7.5 mg capsule, paroxetine ER tablet, protriptyline, trimipramine, Trintellix, venlafaxine ER tablet, vilazodone Tufts Health RITogether Jan. 1, 2024 Antidepressant Medications
Drug status changes
Drug Plan Eff. Date Policy and Additional Information
Aimovig (erenumab-aooe) Tufts Health RITogether Jan. 1, 2024 Pharmacy Products Without Specific Criteria

Aimovig is moving to noncovered status. Prior authorization will be required for new and existing utilizers.

Alvesco (ciclesonide) Tufts Health RITogether Jan. 1, 2024 Pharmacy Products Without Specific Criteria

Alvesco is moving to noncovered status. Prior authorization will be required for new and existing utilizers.

Arnuity Ellipta (fluticasone furoate inhalation powder) and Qvar Redihaler (beclomethasone dipropionate) will continue to be covered without prior authorization.

Effective Jan. 1, 2024, generic fluticasone propionate HFA will be covered without prior authorization.

Basaglar (insulin glargine) KwikPen Tufts Health RITogether Jan. 1, 2024 Pharmacy Products Without Specific Criteria

Basaglar KwikPen is moving to noncovered status. Prior authorization will be required for new and existing utilizers.

Effective Jan. 1, 2024, insulin glargine-yfgn vial and pen will be covered without prior authorization. Insulin glargine-yfgn is not interchangeable with Basaglar, and therefore a new prescription will be required.


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