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 |
| Medical Benefit Step Therapy
Nypozi |
Harvard Pilgrim Commercial
Prior authorization is now required for Nypozi (HCPCS code Q5148) as a non-preferred drug under OncoHealth’s Part B Step Therapy program. |
6/1/2025 |
| Updates to existing prior authorization programs for OncoHealth drugs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Pluvicto | Harvard Pilgrim Commercial
Criteria updated to no longer require that Pluvicto be used with a taxane-based chemotherapy, and to specify that the member being treated with Pluvicto has not received Radium-223 in the prior 6 months and has not received prior PSMA-targeted radioligand therapy. |
4/1/2025 |
| New prior authorization programs | |||
| MNG/Drug(s) | Plan & additional information | Eff. date | |
| Erzofri (paliperidone palmitate)
Antipsychotic Medications |
Tufts Health Together
Prior authorization is now required for Erzofri (HCPCS J3490), approved by the FDA in July 2024 for the treatment of schizophrenia in adults and treatment of schizoaffective disorder in adults as monotherapy and as an adjunct to mood stabilizers or antidepressants. Coverage criteria will be added to the Antipsychotic Medications Medical Necessity Guidelines. |
4/1/2025 | |
| Vyloy (zolbetuximab-clzb)
Unified Medical Policies |
Tufts Health Together
Prior authorization is now required for Vyloy (HCPCS J9999), approved by the FDA in October 2024 in combination with fluoropyrimidine- and platinum-containing chemotherapy for the first-line treatment of adults with locally advanced unresectable or metastatic human epidermal growth factor receptor 2 (HER2)-negative gastric or gastroesophageal junction adenocarcinoma whose tumors are claudin (CLDN) 18.2 positive as determined by an FDA-approved test. Coverage criteria will be unified with MassHealth under the Unified Medical Policies Medical Necessity Guidelines. |
4/1/2025 | |
| Niktimvo (axatilimab-csfr) | Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Prior authorization is now required for Niktivmo (HCPCS J3590), approved by the FDA in August 2024 for the treatment of chronic graft-versus-host disease (cGVHD) after failure of at least two prior lines of systemic therapy in adult and pediatric patients weighing at least 40 kg. |
4/1/2025 | |
| Hympavzi (marstacimab-hncq) | Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care, Tufts Health Plan Commercial, Harvard Pilgrim Health Care Commercial, Tufts Health Direct, Tufts Health RITogether
Prior authorization is now required for Hympavzi (HCPCS J3590), approved by the FDA in October 2024 for routine prophylaxis to prevent or reduce the frequency of bleeding episodes in adult and pediatric patients 12 years of age and older with hemophilia A without factor VIII inhibitors or hemophilia B without factor IX inhibitors. |
4/1/2025 | |
| Aucatzyl (Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options)
Aucatzyl (Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct) |
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options
Prior authorization is now required for Aucatzyl (HCPCS C9301), a CD19-directed genetically modified autologous T cell immunotherapy indicated for the treatment of adults with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL). |
4/1/2025 | |
| Tecelra (Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options)
Tecelra (Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct)
|
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options
Prior authorization is now required for the CAR t-cell medication Tecelra (HCPCS Q2057). |
4/1/2025 | |
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Hemlibra (emicizumab-kxwh) | Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Adding requirement that patients have severe hemophilia as defined by less than 1% of endogenous factor VIII. |
6/1/2025 |
| Pluvicto | Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Criteria updated to no longer require that Pluvicto be used with a taxane-based chemotherapy, and to specify that the member being treated with Pluvicto has not received Radium-223 in the prior 6 months and has not received prior PSMA-targeted radioligand therapy. |
4/1/2025 |
| Breyanzi | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options
Criteria updated to remove a limitation in alignment with National Comprehensive Cancer Network guidelines and published journals. |
4/1/2025 |