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 | Policy & additional information |
| Ibrance | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 10/1/2025 | Updated coverage criteria for Ibrance to require one of the following: contraindication, intolerance, or clinical inappropriateness of treatment with Kisqali and Verzenio OR continuation of prior Ibrance therapy.
Refer to the Antineoplastics Pharmacy Medical Necessity Guideline for details. |
| Non-Formulary Exceptions
|
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 10/1/2025 | Clarified the initial non-formulary coverage criteria for Zepbound in moderate to severe obstructive sleep apnea in obesity to require submission of chart note or medical record with documentation that the member has not been able to tolerate CPAP despite reasonable attempts to adjust to the CPAP and mask. |
| Teriparatide
Tymlos |
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 10/1/2025 | Removed criterion for history of low-trauma osteoporotic fracture. Refer to the Parathyroid Hormones Pharmacy Medical Necessity Guideline for details. |