Tufts Medicare Preferred HMO
2013 Pharmacy Benefit Design and Coverage Changes

Change from Four-Tier to Five-Tier Benefit Design
Beginning January 1, 2013, the Tufts Medicare Preferred HMO Individual Formulary will change from four to five tiers to include a low-cost Preferred Generics tier:

Noncovered Drugs
Effective for fill dates on or after January 1, 2013, Tufts Health Plan Medicare Preferred will no longer cover a number of medications, including drugs with interchangeable generics or therapeutic alternatives.

For brand-name drugs moving to noncovered status, their generic equivalents, if available, will remain covered.

For a patient to continue on one of these noncovered medications, the prescribing provider must request coverage as an exception through the medical review process subject to the Medical Necessity Guidelines for Noncovered Drugs.

Prior Authorization Required for Oral Antiemetics, Oral Antineoplastics and Immunosuppressants
Beginning January 1, 2013, Tufts Medicare Preferred HMO will require prior authorization to determine appropriate coverage under Medicare Part B or Part D for the following drugs:

Oral antiemetics
  • Anzemet®
  • dronabinol
  • EMEND®
  • ondansetron
Oral antineoplastics
  • azathioprine
  • CellCept®
  • cyclosporine
  • cyclosporine modified
  • gengraf
  • Imuran®
  • mycophenolate mofetil
  • Myfortic®
  • Neoral®
  • Rapamune®
  • Sandimmune®
  • tacrolimus
  • cyclophosphamide
  • etoposide
  • methotrexate
  • Myleran®
  • Rheumatrex®
  • Trexall™

Per CMS regulations, the drugs listed above may be covered under Medicare Part B or Part D, depending on the indication and/or situation for which it is prescribed. This coverage distinction should not affect a member’s ability to access a drug, but it will affect his or her cost share (copay or coinsurance) and application of drug cost to his or her Medicare benefit (e.g., True Out-of-Pocket cost) and total drug spend that applies to the member’s Part D benefit.

Claims for the drugs above will not process at the point of sale unless authorization is obtained. Formulary exception requests for 2013 can be submitted to the plan after October 1, 2012. The authorization form Coverage Determination and Prior Authorization Requests for Medicare Part B or Part D is available in the Pharmacy section under the Tufts Health Plan Medicare Preferred tab.

Step Therapy Prior Authorization for Ophthalmic Prostaglandins
Effective for fill dates on or after January 1, 2013, Step Therapy Prior Authorization (PAST) will be required for new starts for the Step 2 medications LumiganĀ®, Travatan ZĀ® and Zioptan™.

Coverage criteria for these medications are documented in the Tufts Health Plan Medicare Preferred Pharmacy Medical Necessity Guidelines for Ophthalmic Prostaglandins Step Therapy.

November 1, 2012
Note: The information in this article was correct as of the date of posting and may not reflect subsequent policy changes.