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 (for oncology purposes) | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Emrelis (telisotuzumab vedotin-tllv) | Harvard Pilgrim Health Care Commercial
Prior authorization is required for new-to-market intravenous drug Emrelis (HCPCS code J9999). |
8/1/25 |
| Avtozma (tocilizumab-anoh) | Harvard Pilgrim Health Care Commercial
Prior authorization is required for new-to-market intravenous drug Avtozma (HCPCS code J3590). |
8/1/25 |
| New prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Niktimvo (axatilimab-csfr) | Tufts Health Together
Prior authorization is now required for Niktimvo (HCPCS J9038), approved by the FDA in August 2024 for the treatment of chronic graft-versus-host disease (cGVHD) after failure of at least two prior lines of systemic therapy in adult and pediatric patients weighing at least 40 kg. Coverage criteria will be unified with MassHealth under the Unified Medical Policies Medical Benefit Drugs Necessity Guidelines. |
8/11/2025 |