The Medical Drug Medical Necessity Guidelines below detail coverage criteria for medical benefit drugs for Harvard Pilgrim Health Care and Tufts Health Plan lines of business. We encourage you to use the drop-down menu to filter applicability by product. We note line of business under the guideline name; however, the policy may not apply to every product in that line of business. Please refer to the policy for product applicability.
Tufts Health Together utilizes MassHealth’s Unified Formulary for pharmacy medications and select medical benefit drugs; for drug coverage and criteria refer to the MassHealth Drug List.
If you are utilizing a medical drug for oncology purposes for a Harvard Pilgrim Health Care Commercial or Stride (HMO/ HMO-POS) Medicare Advantage member, prior authorization is necessary through OncoHealth. For more information, please refer to the OncoHealth link on the Medical Necessity Guidelines page and the Harvard Pilgrim vendor programs resource page.