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 |
| Jubbonti (denosumab-bbdz) | Harvard Pilgrim Commercial
Prior authorization is required for coverage of Jubbonti (Q5136), a biosimilar to Prolia and Sandoz. |
7/1/2025 |
| Osenvelt (denosumab-bbdz) | Harvard Pilgrim Commercial
Prior authorization is required for coverage of Osenvelt (J3590), a biosimilar to Xgeva and Celltrion. |
7/1/2025 |
| Stoboclo (denosumab-bbdz) | Harvard Pilgrim Commercial
Prior authorization is required for coverage of Stoboclo (J3590), a biosimilar to Prolia and Celltrion. |
7/1/2025 |
| Wyost (denosumab-bbdz) | Harvard Pilgrim Commercial
Prior authorization is required for coverage of Wyost (Q5136), a biosimilar to Xgeva and Sandoz. |
7/1/2025 |
| New prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Bendeka (bendamustine) | Tufts Medicare Preferred, Tufts Health One Care, Tufts Health Plan Senior Care Options
Prior authorization will be required for Bendeka (J9034), approved by the FDA in December 2025 for the treatment of chronic lymphocytic leukemia and non-Hodgkin lymphoma. Bendeka will be a non-preferred bendamustine product within the Medical Benefit Step Therapy Medical Necessity Guideline. |
10/1/2025 |
| Posfrea (palonosetron) | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Medicare Preferred, Tufts Health One Care, Tufts Health Plan Senior Care Options
Prior authorization will be required for Posfrea (J2468), approved by the FDA in March 2016 for the treatment of chemotherapy-induced nausea and vomiting in adults and postoperative nausea and vomiting in adults. Posfrea will be a non-preferred antiemetic within the Medical Benefit Step Therapy Medical Necessity Guideline. |
10/1/125 |
| Kebilidi (eladocagene exuparvovec-tneq) | Tufts Health Together
Requires prior authorization through MassHealth for Tufts Health Together members. Being added to MassHealth’s Adjudicated Payment Amount per Discharge (APAD) and Adjudicated Payment per Episode Carve Out Drugs (APEC) lists. |
7/1/2025 |
| Medical Benefit Step Therapy | Tufts Medicare Preferred, Tufts Health One Care, Tufts Health Plan Senior Care Options, Tufts Health Plan Commercial, Harvard Pilgrim Health Care Commercial, Tufts Health Direct
Prior authorization is now required for Opuviz (Q5153), approved by the FDA in May 2024 for the treatment of neovascular (wet) age-related macular degeneration, macular edema following retinal vein occlusion, diabetic macular edema, and diabetic retinopathy. Opuviz will be a non-preferred retinal disorder product within the Medical Benefit Step Therapy Medical Necessity Guideline. |
7/1/2025 |
| Targeted Immunomodulators-Skilled Administration | Tufts Medicare Preferred, Tufts Health One Care, Tufts Health Plan Senior Care Options
Prior authorization is now required for the following FDA-approved Stelara biosimilars Imuldosa (Q5098), Otulfi (Q9999), Pyzchiva (Q9996, Q9997), Selarsdi (Q9998), Steqeyma (Q5099), Wezlana (Q5137, Q5138), and Yesintek (Q5100). |
7/1/25 |
| Vyalev (foscarbidopa/foslevodopa) | 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 Vvyalev (J7356), approved by the FDA in October 2024 for the treatment of motor fluctuations in adults with advanced Parkinson’s disease. |
7/1/2025 |
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Adstiladrin | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health RITogether, Tufts Health Direct
Policy related to coverage of Adstiladrin (J9029) updated to reflect recent National Comprehensive Cancer Network guidance: removed reference that the non-muscle invasive bladder cancer must be “in situ.” |
7/1/2025 |
| Amtagvi | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health RITogether, Tufts Health Direct
For coverage of Amtagvi (J3590), provider must document that active systemic infections (viral, bacterial, fungal) have been excluded at the time of tissue harvesting and are not present at the time of infusion. |
7/1/2025 |
| Removal of Prior Authorization | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Neulasta | Harvard Pilgrim Commercial
Removing prior authorization for J2506 (injection, pegfilgrastim, excludes biosimilar, 0.5 mg) |
7/1/2025 |
| Fulphila | Harvard Pilgrim Commercial
Removal of prior authorization for Q5108 [Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mg] |
7/1/2025 |