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 programs for OncoHealth drugs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Avzivi (Bevacizumat-tnjn)
Medicare Part B Step Therapy Medical Benefit Drugs Medical Necessity Guidelines |
Harvard Pilgrim Health Care Commercial
Avzivi (J9999), a humanized monoclonal antibody that inhibits vascular endothelial growth factor and a biosimilar of Avastin, has been designated as non-preferred. Coverage will only be authorized for members who have first tried the preferred drugs Zirabev and Mvasi. |
6/1/2025 |
| Updates to existing prior authorization programs for OncoHealth drugs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Neulasta (Pegfilgrastim, excludes biosimilar, 0.5 mg)
|
Harvard Pilgrim Health Care Commercial
Prior authorization will no longer be managed by OncoHealth, but should be submitted directly to Point32Health via PromptPA. |
6/1/2025 |
| Fulphila (Pegfilgrastim-jmdb, biosimilar, 0.5 mg)
|
Harvard Pilgrim Health Care Commercial
Prior authorization will no longer be managed by OncoHealth, but should be submitted directly to Point32Health via PromptPA. |
6/1/2025 |
| Varubi (Rolapitant inj, 0.5 mg) | Harvard Pilgrim Health Care Commercial
Prior authorization is no longer required for Varubi (J2797). |
6/1/2025 |
| Aliqopa (Canalize inj, 1 mg) | Harvard Pilgrim Health Care Commercial
Prior authorization is no longer required for Aliqopa (J9057) |
6/1/2025 |
| DepoCyt (Cytarabine Liposome Inj, 10 mg) | Harvard Pilgrim Health Care Commercial
Prior authorization is no longer required for DepoCyt (J9098). |
6/1/2025 |
| Sylatron (NOC, antineoplastic drugs)
PegIntron (NOC, antineoplastic drugs) |
Harvard Pilgrim Health Care Commercial
Prior authorization is no longer required for Sylatron (J9999) or PegIntron (J9999). |
6/1/2025 |
| Lacluze (NOC, antineoplastic drugs) | Harvard Pilgrim Health Care Commercial
Prior authorization is no longer required for Lacluze (J9999). |
6/1/2025 |
| New prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Brixadi (buprenorphine) | Tufts Health Together
Prior authorization is now required for Brixadi (HCPCS J0577 and J0578), approved by the FDA in December 2023 for the treatment of moderate to severe opioid use disorder in patients who have initiated treatment with a single dose of a transmucosal buprenorphine product or who are already being treated with buprenorphine. Coverage criteria will be unified with MassHealth under the Unified Medical Policies Medical Benefit Drugs Necessity Guidelines. |
8/1/2025 |
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Zolgensma (onasemnogene abeparvovec) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
The medical drug MNG for Zolgensma specific to Tufts Health RITogether has been retired, and this information is now included in the broader medical drug MNG applicable to Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, and now Tufts Health RITogether. |
6/1/2025 |
| Luxturna (voretigene neparvovec-rzyl) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
The medical drug MNG for Luxturna specific to Tufts Health RITogether has been retired, and this information is now included in the broader medical drug MNG applicable to Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, and now Tufts Health RITogether. |
6/1/2025 |