The chart below identifies updates for Pharmacy Medical Necessity Guidelines. For additional details and to access the guidelines referenced below, please visit the Pharmacy Medical Necessity Guidelines page on our Point32Health provider website.
| Updates to existing prior authorization programs | ||||||
| Drug | Plan | Eff. date | Additional information | |||
| Abrilada (adalimumab-afzb), Amjevita (adalimumab-atto), Cyltezo (adalimumab-adbm), Hadlima (adalimumab-bwwd), Hulio (adalimumab-fkjp), Hyrimoz (adalimumab-adaz), Idacio (adalimumab-aacf), Simlandi (adalimumab-ryvk), Yuflyma (adalimumab-aaty), and Yusimry (adalimumab-aqvh) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Adalimumab products will continue to be non-formulary; however, the coverage criteria will be updated to be drug and therapeutic category specific. Refer to the Adalimumab Products policy for details on the medications listed at left. | |||
| Cosentyx (secukinumab) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Cosentyx will continue to be non-formulary; however, the coverage criteria will be updated to be drug and therapeutic category specific. | |||
| Ebglyss (lebrikizumab-lbkz) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Ebglyss will continue to be non-formulary; however, the coverage criteria will be updated to be drug and therapeutic category specific. | |||
| Entyvio Pen and Entyvio pre-filled syringe (vedolizumab) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Entyvio Pen and Entyvio pre-filled syringe will continue to be non-formulary; however, the coverage criteria will be updated to be drug and therapeutic category specific. Refer to the Entyvio Subcutaneous Products policy. | |||
| Kevzara (sarilumab) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Kevzara will continue to be non-formulary; however, the coverage criteria will be updated to be drug and therapeutic category specific. | |||
| Kineret (anakinra) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Kineret will continue to be non-formulary; however, the coverage criteria will be updated to be drug and therapeutic category specific. | |||
| Nemluvio (nemolizumab-ilto) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Nemluvio will continue to be non-formulary; however, the coverage criteria will be updated to be drug and therapeutic category specific. | |||
| Siliq (brodalumab) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Siliq will continue to be non-formulary; however, the coverage criteria will be updated to be drug and therapeutic category specific. | |||
| Sotyktu (deucravacitinib) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Sotyktu will continue to be non-formulary; however, the coverage criteria will be updated to be drug and therapeutic category specific. | |||
| Tyenne (tocilizumab-aazg) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Tyenne will continue to be non-formulary; however, the coverage criteria will be updated to be drug and therapeutic category specific. Refer to the Tocilizumab Subcutaneous Products Pharmacy Medical Necessity Guideline for details. | |||
| Velsipity (etrasimod) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Velsipity will continue to be non-formulary; however, the coverage criteria will be updated to be drug and therapeutic category specific | |||
| Zymfentra (infliximab-dyyb) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Zymfentra will continue to be non-formulary; however, the coverage criteria will be updated to be drug and therapeutic category specific | |||
| Contrave (naltrexone/bupropion)
Zepbound (tirzepatide)
|
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Added limitation statement that members who have not been on the requested medication through the plan in the previous 12 months will be reviewed against Initial Criteria. Updated the limitation statement that members who have already initiated the requested medication by self-paying for the medication directly do not qualify for established clinical response and should be reviewed against initial approval criteria. Refer to the Weight Loss Medications Pharmacy Medical Necessity Guideline. | |||
| Drug status changes | ||||||
| Drug | Plan | Eff. Date | Additional information | |||
| OneTouch Test Strips manufactured by Lifescan | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | All OneTouch Test strips will be moved to non-formulary status. For more information, please refer to the related article in this issue. | |||
| OneTouch Glucometers | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | All OneTouch Glucometers will move to excluded status. For more information, please refer to the related article in this issue. | |||
| Revlimid (lenalidomide) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Brand Revlimid will be moved to non-formulary status. Point32Health provides coverage for generic lenalidomide. | |||
| Stelara (ustekinumab) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 9/1/2025 | Stelara will be moving to non-formulary status and the coverage criteria will be drug and therapeutic category specific. For more information, please refer to the related article in this issue and the Ustekinumab Subcutaneous Products Pharmacy Medical Necessity Guideline. | |||