Point32Health is making an update to our coverage process for new-to-market pharmacy benefit drugs, which will take effect on June 1, 2026 for members of our Harvard Pilgrim Health Care and Tufts Health Plan Commercial plans, as well as Tufts Health Direct. 

As of that date, any requests for a new-to-market pharmacy drug will be denied as a benefit exclusion until Point32Health’s Pharmacy and Therapeutics Committee has reviewed the drug for safety and clinical effectiveness and made the determination to cover it. A new drug product will be excluded from coverage until this process is completed — which will occur by Dec. 31 of the following calendar year, or as may be required by law (whichever is earliest). 

When a new-to-market pharmacy drug is denied, an exception may be granted upon second request only for members who are suffering from a health condition that may seriously jeopardize their life, health, or ability to regain maximum function. These requests are reviewed against the criteria outlined in our Pharmacy Medical Necessity Guidelines (PMNG) for Non-Formulary Exceptions, which will be updated in alignment with the June 1 effective date. 

Additionally, our New-to-Market Drugs PMNG will be retired on May 31, 2026 to reflect this process change. 

This change in process was initially planned for an April 1 effective date but was delayed until June 1. 

Keep in mind that medical benefit drugs are not currently in scope for this change, and there is no impact to current utilizers of new-to-market pharmacy drugs — only for those who request coverage on or after June 1.