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
|
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 |