Back to Insights and Updates for ProvidersJune 2024

Point32Health medical drug program updates

All products

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 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 for OncoHealth drugs
MNG/Drug(s) Plan & additional information Eff. date
 

Anktiva

 

Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage

Bill using HCPCS code J9999

 

6/1/2024

Hercessi Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage

Bill using HCPCS code J9999

6/1/2024

 

Updates to existing prior authorization programs
MNG/Drug(s) Plan & additional information Eff. date

 

 

Respiratory Interleukins

  • Cinqair (resliuzumab)
  • Fasenra (benralizumab)
  • Nucala (mepolizumab
 

Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether

 

8/1/2024

Tezspire (tezepelumab-ekko) Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether 8/1/2024
Xolair (omalizumab) 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 8/1/2024
Casgevy Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether

Casgevy (HCPCS J3490) will now be covered, with prior authorization, for a newly FDA-approved indication: treatment-resistant beta thalassemia.

6/1/2024
Breyanzi Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Medicare Preferred, Tufts Health Plan Senior Care Options

Breyanzi (HCPCS Q2054) will now be covered, with prior authorization, for Chronic Lymphocytic Leukemia (CLL) or Small Lymphocytic Lymphoma (SLL).

6/1/2024