The chart below identifies updates to our medical benefit drug program. For additional details, refer to the Medical Necessity Guidelines associated with the medical drug in question, which you can find on our Point32Health (the parent company of Harvard Pilgrim Health Care and Tufts Health Plan) Medical Benefit Drug Medical Necessity Guidelines page.
Alternatively, some medical drugs are managed through an arrangement with OncoHealth when utilized for oncology purposes for Harvard Pilgrim members. You can find information about this program on the OncoHealth page in the Vendor Programs section of Point32Health’s provider website and you can access the prior authorization policies for these drugs directly on OncoHealth’s webpage for Harvard Pilgrim.
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.
| New prior authorization for OncoHealth drugs (for oncology purposes) For Harvard Pilgrim Health Care Commercial members | ||
| MNG/Drug(s) | Additional information | Eff. date |
| Actemra | Prior authorization will be required for Actemra (J3262). | |
| Tofidence (tocilizumab-bavi) | Prior authorization will be required for Tofidence (tocilizumab-bavi) (Q5133), a biosimilar of Actemra (tocilizumab). | 11/1/2025 |
| Tyenne (tocilizumab-aazg) | Prior authorization will be required for Tyenne (tocilizumab-aazg) (Q5135), a biosimilar of Actemra (tocilizumab). | 11/1/2025 |
| Dr. Reddy’s bendamustine | Prior authorization is required for Dr. Reddy’s bendamustine (J9999). | 9/1/2025 |
Denosumab-BHNT, including:
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Prior authorization is required for Bomyntra (denosumab-BHNT) (J3590), a biosimilar to Xgeva (denosumab).
|
9/1/2025 |
| Lynozyfic (linvoseltamab-gcpt) | Prior authorization is required for Lynozyfic (linvoseltamab-gcpt) (J9999). | 9/1/2025 |
| Avgemsi (gemcitabine) | Prior authorization is required for Avgemsi (gemcitabine) (J9999). | 9/1/2025 |
| Penpulimab-kcqx | Prior authorization is required for penpulimab-kcqx (J9999), a programmed death ligand-1 blocking antibody used to treat adults with recurrent or metastatic non-keratinizing nasopharyngeal carcinoma (NPC). | 8/1/2025 |
| New prior authorization programs | ||
| Drug/MNG | Plan & additional information | Eff. date |
| Onapgo (apomorphine)
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Havard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Prior authorization is now required for Onapgo (HCPCS J3490), approved by the FDA in February 2025 for the treatment of motor fluctuations in adults with advanced Parkinson’s disease. Coverage criteria will be added to the Advanced Parkinson’s Disease Medications Medical Necessity Guideline. |
9/1/2025 |
| Updates to existing prior authorization programs | ||
| Drug/MNG | Plan & additional information | Eff. date |
| Abecma (idecabtagene vicleucel) | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options
Removal of language stating that Abecma is only available through a restricted Risk Evaluation and Mitigation Strategy (REMS) program. Clarification of limitation related to immunosuppressive therapy to note that this limitation applies if the therapy is likely to interfere with T cell function. |
9/1/2025 |
| Aucatzyl (obecabtagene autoleucel) | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Clarification of limitation related to immunosuppressive therapy to note that this limitation applies if the therapy is likely to interfere with T cell function. |
9/1/2025 |
| Breyanzi (lisocabtagene maraleucel) | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options
Removal of language stating that Breyanzi is only available through a restricted Risk Evaluation and Mitigation Strategy (REMS) program. Clarification of limitation related to immunosuppressive therapy to note that this limitation applies if the therapy is likely to interfere with T cell function. Addition of new indication for pediatric aggressive mature B cell lymphomas for Commercial and Public Plans members. |
9/1/2025 |
| Carvykti (ciltacabtagene autoleucel) | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options
Removal of language stating that Carvykti is only available through a restricted Risk Evaluation and Mitigation Strategy (REMS) program. Clarification of limitation related to immunosuppressive therapy to note that this limitation applies if the therapy is likely to interfere with T cell function. |
9/1/2025 |
| Kymriah (tisagenlecleucel) | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options
Removal of language stating that Kymriah is only available through a restricted Risk Evaluation and Mitigation Strategy (REMS) program. Clarification of limitation related to immunosuppressive therapy to note that this limitation applies if the therapy is likely to interfere with T cell function. |
9/1/2025 |
| Tecartus (brexucabtagene autoleucel) | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options
Removal of language stating that Tecartus is only available through a restricted Risk Evaluation and Mitigation Strategy (REMS) program. Clarification of limitation related to immunosuppressive therapy to note that this limitation applies if the therapy is likely to interfere with T cell function. |
9/1/2025 |
| Yescarta (axicabtagene ciloleucel) | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options
Removal of language stating that Yescarta is only available through a restricted Risk Evaluation and Mitigation Strategy (REMS) program. Clarification of limitation related to immunosuppressive therapy to note that this limitation applies if the therapy is likely to interfere with T cell function. Addition of new indication for pediatric aggressive mature B cell lymphomas for Commercial and Public Plans members. |
9/1/2025 |