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.
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Adstiladrin | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Minor updates to criteria to reflect updates to National Comprehensive Cancer Network guidelines. |
5/1/2025 |
| MassHealth Adjudicated Payment Amount per Discharge and Adjudicated Payment per Episode Carve Out Drugs
Aucatzyl |
Prior authorization for coverage of Aucatzyl (HCPCS C9308) will now be managed by MassHealth. The drug will be covered when all criteria outlined by MassHealth are met. | 5/12/2025 |
| MassHealth Adjudicated Payment Amount per Discharge and Adjudicated Payment per Episode Carve Out Drugs
Zynteglo |
Minor update to MassHealth’s prior authorization coverage criteria for Zynteglo. | 5/12/2025 |