Does Tufts Health Plan Cover Dupixent?

How Tufts Health Plan Classifies Dupixent on Its Formulary

Tufts Health Plan places Dupixent (dupilumab) on its specialty pharmacy tier across most commercial and managed care formularies. Specialty-tier placement means higher out-of-pocket costs compared to preferred generics, but it also means the drug is an accessible benefit rather than excluded entirely.

Tufts contracts with specialty pharmacies to dispense Dupixent, which is a self-injectable biologic manufactured by Sanofi and Regeneron. Patients receive shipments directly to their home, typically in pre-filled syringes or pens. The plan requires that prescriptions route through designated specialty pharmacy channels rather than retail pharmacies.

Formulary placement can shift year to year. The Tufts Health Plan formulary documents, updated annually and accessible through the Tufts Health Plan member portal, specify the tier, any quantity limits, and applicable utilization management. Patients should verify their specific plan document because Tufts administers multiple product lines: Tufts Health Plan (commercial/employer), Tufts Health Together (MassHealth ACO), and Tufts Medicare Preferred (senior HMO). Each product line maintains its own formulary rules.

The distinction matters. A Tufts Health Together (Medicaid) enrollee may face different step-therapy sequences than a commercially insured member on a Tufts PPO plan. Employer-sponsored self-funded plans administered by Tufts can also customize their formulary, meaning some employers may impose stricter or more lenient criteria than Tufts' standard commercial formulary.

Prior Authorization Requirements for Dupixent Under Tufts

Every Tufts Health Plan product requires prior authorization before Dupixent dispensing. This is standard across U.S. commercial insurers for biologics, and Tufts is no exception. The prior authorization process verifies that the patient meets clinical criteria and that less expensive alternatives have been tried.

For moderate-to-severe atopic dermatitis, Tufts typically requires documentation of the following before approving Dupixent: a confirmed diagnosis of moderate-to-severe atopic dermatitis (often defined by an Investigator Global Assessment score of 3 or 4, or an Eczema Area and Severity Index score of 16 or higher), an inadequate response to or intolerance of at least one topical corticosteroid and/or topical calcineurin inhibitor used for a minimum duration (usually 3 months), and in some plan documents, failure of at least one systemic immunosuppressant such as methotrexate, cyclosporine, or mycophenolate mofetil.

The FDA approved dupilumab for moderate-to-severe atopic dermatitis in adults in March 2017, based on the SOLO 1 and SOLO 2 trials. In SOLO 1 (N=671), 38% of patients receiving dupilumab 300 mg every two weeks achieved clear or almost-clear skin (IGA 0/1) at week 16, compared with 10% of placebo-treated patients. The LIBERTY AD CHRONOS trial (N=740) demonstrated that dupilumab plus topical corticosteroids produced a 69% mean improvement in EASI score at 52 weeks versus 23% with placebo plus topical corticosteroids.

Tufts prior authorization approvals are typically granted for 12 months, after which reauthorization is required. The prescriber must submit clinical notes showing continued medical necessity and ongoing treatment response.

Step Therapy: What You Need to Try First

Step therapy is the most common barrier Tufts Health Plan members encounter when seeking Dupixent coverage. The plan requires evidence that conventional, lower-cost treatments have failed before authorizing a biologic that costs over $3,000 per month.

For atopic dermatitis, the step-therapy ladder generally follows this sequence: first-line topical corticosteroids (such as triamcinolone or clobetasol) for a minimum of 3 months, then topical calcineurin inhibitors (tacrolimus or pimecrolimus), and in some plan variants, a trial of a systemic immunosuppressant. Dupixent sits above these steps.

This sequencing aligns with the American Academy of Dermatology guidelines, which recommend topical therapies as first-line treatment for atopic dermatitis and reserve systemic agents for patients with inadequate responses. The AAD's 2023 guideline update recognized dupilumab as a first-line systemic option for moderate-to-severe atopic dermatitis, noting its favorable long-term safety profile compared to traditional immunosuppressants like cyclosporine.

For asthma, the step-therapy path is different. Tufts generally requires documentation that the patient is on a medium-to-high-dose inhaled corticosteroid plus a long-acting beta-agonist (ICS/LABA combination), has blood eosinophils of 150 cells/mcL or higher (or FeNO of 25 ppb or higher), and remains uncontrolled despite this regimen. The LIBERTY ASTHMA QUEST trial (N=1,902) showed that dupilumab reduced severe asthma exacerbations by 47.7% in the overall population and by 65.8% in patients with baseline eosinophils of 300 cells/mcL or higher.

If a prescriber documents that a required step-therapy drug is contraindicated or clinically inappropriate, Tufts allows an exception request. Contraindications, documented adverse reactions, and drug interactions are valid grounds for bypassing a step.

What Dupixent Costs Under Tufts Health Plan

The sticker price for Dupixent is approximately $3,300 to $3,500 per month, translating to an annual wholesale acquisition cost (WAC) near $36,000 to $41,000. Tufts Health Plan members will not pay the full list price, but their out-of-pocket costs depend on their specific plan design.

Members on commercial Tufts plans with a specialty-tier copay may owe 20% to 30% coinsurance after meeting their deductible. For a drug costing $3,400 per month, 25% coinsurance equals $850 per fill. Plans with an out-of-pocket maximum will cap annual costs, typically between $4,000 and $8,550 for individual coverage (the 2026 ACA out-of-pocket maximum is $9,200).

Sanofi and Regeneron operate the Dupixent MyWay copay card program, which can reduce out-of-pocket costs to as low as $0 per month for eligible commercially insured patients. The program covers up to $13,000 per year in copay or coinsurance expenses. This assistance is available to patients with commercial insurance, including those on Tufts Health Plan commercial products. It is not available to patients on government-funded plans such as Tufts Health Together (MassHealth) or Tufts Medicare Preferred.

For Tufts Medicare Preferred enrollees, Part D coverage applies. Dupixent falls under Medicare Part D specialty tiers, where coinsurance in the catastrophic phase drops to 5% after the patient reaches the out-of-pocket threshold ($2 to 000 in 2025 under the Inflation Reduction Act cap). This means Medicare enrollees on Tufts senior plans face significantly lower annual exposure than they would have before the IRA cap took effect.

Dr. Jonathan Silverberg, a dermatologist at George Washington University, has noted: "Insurance coverage for dupilumab has improved substantially since its 2017 launch, but step-therapy requirements remain the primary obstacle. Most patients can get approved if their physicians document treatment history thoroughly."

FDA-Approved Indications That Tufts May Cover

Dupixent's label has expanded considerably since its initial 2017 approval for atopic dermatitis. Each new indication creates a separate coverage pathway within Tufts' prior authorization system.

The current FDA-approved indications for dupilumab include: moderate-to-severe atopic dermatitis in patients aged 6 months and older, moderate-to-severe asthma in patients aged 6 years and older with an eosinophilic phenotype or oral corticosteroid-dependent asthma, chronic rhinosinusitis with nasal polyps (CRSwNP) in adults, eosinophilic esophagitis (EoE) in patients aged 1 year and older weighing at least 15 kg, and prurigo nodularis in adults. The FDA also approved dupilumab for chronic obstructive pulmonary disease (COPD) with type 2 inflammation in September 2024, making it the first biologic approved for COPD.

Tufts Health Plan's coverage criteria differ by indication. For CRSwNP, the SINUS-24 trial (N=276) demonstrated that dupilumab improved nasal polyp score by 1.89 points versus placebo and improved the Lund-Mackay CT score by 8.8 points at 24 weeks. Tufts typically requires documentation of failed intranasal corticosteroid therapy and, in some cases, prior sinus surgery or a history of systemic corticosteroid courses.

For eosinophilic esophagitis, the Part A of the phase 3 trial (N=81) showed that 60% of patients on dupilumab achieved histologic remission (peak esophageal eosinophil count of 6 or fewer per high-power field) at 24 weeks versus 5% on placebo. Tufts coverage for EoE generally requires documented failure of proton pump inhibitor therapy and potentially a swallowed topical corticosteroid.

How to Manage the Approval Process With Tufts

Getting Dupixent approved through Tufts Health Plan follows a predictable workflow. Start with your prescribing physician submitting the prior authorization request, which Tufts calls a "medication request" in its pharmacy benefits system.

The prescriber should include: the specific diagnosis with ICD-10 code, clinical severity measures (EASI score, IGA score, pulmonary function tests, or endoscopy findings depending on the indication), a list of prior treatments with dates, durations, and outcomes, and any relevant lab values such as blood eosinophil counts, total IgE, or FeNO levels.

Tufts processes pharmacy prior authorization requests within 72 hours for standard requests and within 24 hours for urgent requests. If the initial request is denied, Tufts provides a written explanation citing the specific coverage criteria that were not met. The prescriber can then file a first-level appeal, and if that fails, a second-level appeal reviewed by an independent physician reviewer.

Massachusetts state law (M.G.L. c. 176O, § 13) requires health plans to complete internal appeals within 30 days for standard appeals and 72 hours for urgent/expedited appeals. If both internal appeals are denied, the patient can request an external review through the Massachusetts Office of Patient Protection, which assigns an independent review organization (IRO) to evaluate the case. According to the Massachusetts Division of Insurance, external reviews overturn insurer denials in approximately 40% to 50% of cases involving specialty biologics.

Dr. Emma Guttman-Yassky, director of the Center of Excellence in Eczema at the Icahn School of Medicine at Mount Sinai, has stated: "The step-therapy requirements that most insurers impose for dupilumab are manageable when clinicians document the patient's treatment journey carefully. The clinical trial evidence is strong enough that most appeals succeed when the paperwork is complete."

Tufts Health Together (MassHealth) and Dupixent

Tufts Health Together, the plan's MassHealth (Medicaid) ACO product, covers Dupixent under the MassHealth Drug List, but the criteria and process differ from commercial coverage.

MassHealth maintains its own preferred drug list and prior authorization protocols. Dupilumab is covered under MassHealth with prior authorization for atopic dermatitis and asthma, consistent with the MassHealth Drug List. The MassHealth criteria tend to follow FDA labeling closely but require step therapy through topical therapies and, for atopic dermatitis, typically a trial of a systemic immunosuppressant.

One difference for MassHealth enrollees: manufacturer copay cards are not available. Federal anti-kickback statutes prohibit manufacturer copay assistance for patients on government-funded insurance. However, MassHealth members generally face much lower cost-sharing than commercially insured patients. Many MassHealth plans have no copay or a nominal copay ($1 to $3) for specialty medications once prior authorization is obtained.

Tufts Health Together members who are denied coverage can appeal through both the Tufts internal process and the MassHealth Board of Hearings. The dual appeal pathway gives MassHealth enrollees an additional layer of review that is not available to commercial members.

Comparing Tufts' Dupixent Coverage to Other Massachusetts Insurers

Tufts Health Plan's Dupixent coverage criteria are broadly comparable to those of other major Massachusetts insurers. Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care (now part of Point32Health along with Tufts), and Mass General Brigham Health Plan all require prior authorization and step therapy for dupilumab.

The 2024 merger of Tufts Health Plan and Harvard Pilgrim under Point32Health means that formulary management is increasingly centralized. Members on either legacy brand may see their formulary criteria converge over time, though as of 2026, some differences in step-therapy requirements and preferred specialty pharmacies persist between Tufts-branded and Harvard Pilgrim-branded plans.

A 2023 analysis published in JAMA Dermatology (N=1,206 prior authorization requests) found that initial prior authorization approval rates for dupilumab across U.S. commercial insurers averaged 73%, with an additional 18% approved on first appeal. The combined approval rate exceeded 90% when prescribers submitted complete documentation including severity scores and treatment history.

These figures suggest that most Tufts members who meet clinical criteria will obtain coverage, though the process requires patience and thorough documentation from their prescribing physician.

Dupixent Biosimilar Outlook and Future Cost Changes

No biosimilar for dupilumab is available as of mid-2026. Sanofi/Regeneron hold patent protections on Dupixent that extend into the early 2030s, with key composition-of-matter patents not expiring until approximately 2031. Several biosimilar manufacturers have filed abbreviated Biologics License Applications (aBLAs) with the FDA, but none have received approval yet.

When biosimilars do enter the market, Tufts Health Plan (and other insurers) will likely prefer them over branded Dupixent due to lower acquisition costs, typically 15% to 35% below the reference biologic's price. This could reshape step therapy: insurers may require a biosimilar trial before covering branded Dupixent, similar to how generic substitution works for small-molecule drugs.

For now, Tufts members should focus on maximizing available cost-reduction strategies: the Dupixent MyWay copay card (for commercial plans), the Sanofi Patient Assistance Program (for uninsured or underinsured patients), and ensuring their prescriber submits a thorough prior authorization packet on the first attempt to avoid delays.

Patients whose annual out-of-pocket costs exceed their plan's maximum will see costs drop to $0 for the remainder of the benefit year. Tracking when you hit this threshold can help you plan the timing of other medical expenses.