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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