Tufts Health Plan 60-Day Notification
Effective January 1, 2010
Commercial Pharmacy Coverage Changes

Non-Covered Medications
Effective for fill dates on or after January 1, 2010, Tufts Health Plan will no longer cover the following medications, and will move these drugs to the List of Non-Covered Drugs with Suggested Alternatives in its commercial formularies: [

• Fosamax®
• Fosamax Plus D™
• Fosamax Plus D™
• Nexium®
• Prevacid®
• Proscar®
• Protonix®

This coverage change applies to the brand name drugs only. Their generic equivalents will remain covered on Tier 1. For a patient to continue on a brand name agent, providers must request coverage through the Medical Review process subject to the Medical Necessity Guidelines for Non-Covered Drugs with Selected Alternatives.

Step Therapy Changes: Bisphosphonates and PPIs
Effective for fill dates on and after January 1, 2010, Step Therapy Prior Authorization will be required for the bisphosphonates and proton pump inhibitors (PPIs).

• Bisphosphonates: Boniva® and Actonel® (Step 2) will require a trial of alendronate (Step 1) before being covered. Members currently filling for Boniva or Actonel will be allowed to continue on their current regimen. Any member having filled for brand name Fosamax or Fosamax Plus D can fill for a Step 1 or Step 2 drug. 
• PPIs: Omeprazole will be covered on Step 1, and lansoprazole (generic Prevacid, when released) and pantoprazole will be covered on Step 2. No brand name PPIs will be covered. Members currently filling for lansoprazole, omeprazole or pantoprazole will be allowed to continue on their current regimen. Any member having filled for the brands Nexium, Prevacid or Protonix can fill for a Step 1 or Step 2 drug, provided it is within the Dispensing Limit (DL) of one (1) capsule or tablet per day. If the member was previously approved for an override of the DL, they will be allowed to fill for any one of the covered generics at the approved DL.

Coverage Change for Lidoderm®
Effective for fill dates on or after January 1, 2010, Tufts Health Plan will require prior authorization for coverage of Lidoderm (lidocaine patch 5%).  

Approval will be based on the member’s having a documented diagnosis of pain associated with post-herpetic neuralgia. The current dispensing limitation of 30 patches per 30 days will remain in effect.

Tufts Health Plan will not authorize the use of Lidoderm for any other condition without clinical justification.

Gonadotropin Dispensing Guidelines
Effective January 1, 2010, Tufts Health Plan will change the dispensing guidelines for gonadotropins used in conjunction with in vitro fertilization (IVF) from 4500 units per cycle to 3600 units per cycle. Justification for doses exceeding these limits must be submitted to the designated Infertility Specialty Pharmacy.

Covered Under Prescription Drug Benefit
Effective for claims adjudicated on and after January 1, 2010, the following drugs will only be covered under the member’s prescription drug benefit and will not be covered under the medical benefit. These drugs must be obtained by the member at the appropriate designated specialty pharmacy.

• Apokyn® (J0364 – Injection, apomorphine hydrochloride, 1 mg)
• Fuzeon®  (J1324 – Injection, enfuvirtide, 1 mg)
• Hycamtin® (J8705 – Topotecan, oral, 0.25 mg)
• Increlex® (J2170 – Injection, mecasermin, 1 mg)
• Infergen® (J9212  – Injection, interferon Alfacon-1, recombinant, 1 microgram)
• Temodar® (J8700 – Temozolomide, oral, 5 mg)
• Xeloda® (J8520 – Capecitabine, oral, 150 mg, J8521 – Capecitabine, oral, 500 mg)

Coverage Change for Flolan® and Generic Epoprostenol
Effective December 1, 2009, Tufts Health Plan members for whom treatment with Flolan® is indicated will be required, as a condition of treatment, to first utilize the generic version epoprostenol, provided that the member meets coverage criteria in the Pharmacy Medical Necessity Guidelines for Pulmonary Hypertension.

November 1, 2009
Note: The information in this article was correct as of the date of posting and may not reflect subsequent policy changes.