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 Medical Benefit Drug Medical Necessity Guidelines page. Point32Health is the parent company of Harvard Pilgrim Health Care and Tufts Health Plan.
Alternatively, some medical drugs are managed through an arrangement with OncoHealth when utilized for oncology purposes for Harvard Pilgrim Commercial and Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage members. You can find information about this program on the OncoHealth page in the Vendor Programs section of the Harvard Pilgrim 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.
| Visit our new Medical Drug Medical Necessity Guidelines page to access these policies (unless otherwise noted). | |||
| New prior authorization programs | |||
| MNG/Drugs | Plan | Eff. date | Summary |
| Targeted Immunomodulators Skilled Administration | Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | March 1, 2024 | Prior authorization is now required for Cosentyx IV (HCPCS J3590), approved by the FDA in October 2023 for the treatment of ankylosing spondylitis, non-radiographic axial spondyloarthritis, and psoriatic arthritis. |
| Veopoz (pozelimab-bbfg) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Together | March 1, 2024 | Prior authorization is now required for Veopoz (HCPCS J3590), approved by the FDA in August 2023 for the treatment of adult and pediatric patients 1 year of age and older with CD55-deficient protein-losing enteropathy (PLE), also known as CHAPLE disease. |
| Long-Acting GCSFs | Harvard Pilgrim Health Care Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage | Mar 1, 2024 | Prior authorization is now required for Ryzneuta (HCPCS J3590).
Refer to the Long-Acting GCSFs policy on OncoHealth’s webpage for Harvard Pilgrim. |
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Tecvayli (teclistamab-cqyv) | Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health MATogether. Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | May 1, 2024 |
| Medicare Part B Step Therapy:
Akynzeo, Alymsys, Aponvie, Avastin, Avsola, Beovu, Byooviz, Cimerli, Cinvanti, Durolane, Dysport, Elelyso, Evenity, Eylea, Feraheme, Fusilev, Fylnetra, Gel-One, Gelsyn-3, Genvisc 850, Granix, Herceptin, Herceptin Hylecta, Herzuma, Hyalgan, Hymovis, Injectafer, Khapzory, Lanreotide (cipla), Leukine, LEVOleucovorin, Lucentis, Monoferric, Monovisc, Myobloc, Neupogen, Nivestym, Nyvepria, Ogivri, Ontruzant, Orthovisc, Prolia, Releuko, Renflexis, Riabni, Rituxan, Rituxan Hycela, Rolvedon, Signifor LAR, Soliris, Stimufend, Supartz FX, Sustol, Susvimo, Synojoynt, Synvisc One, Synvisc, Treanda, Triluron, Trivisc, Udenyca, Vabysmo, Vegzelma, Visco-3, Visudyne, Vivimusta, Xgeva, Ziextenzo, Zilretta |
Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | May 1, 2024 |
| Oxlumo (lumasiran) | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | May 1. 2024 |
| Zolgensma | Tufts Health Together
Minor update to the Zolgensma prior authorization criteria located on the MassHealth Drug List. |
March 4, 2024 |
| Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether
Minor updates to the criteria for these chimeric antigen receptor (CAR) T-cell therapy drugs. For Tufts Health Together criteria, refer to the MassHealth Drug List. |
March 1, 2024 |
| Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Added criteria for allow for outpatient administration consistent with REMS program requirements. |
March 1, 2024 |