Back to Insights and Updates for ProvidersOctober 2023

Point32Health medical drug program updates

All products

New prior authorization programs

MNG Title Products Affected Effective Date Summary
Epkinly
Epkinly
 Tufts Health Plan commercial, Tufts Health Public Plans, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options Dec. 1, 2023 Prior authorization will be required for the drug Epkinly (HCPCS J9999), approved by the FDA in May 2023 to treat large B-cell lymphoma and high-grade B-cell lymphoma.
Vyvgart Hytrulo
(efgartigimod alfa and hyaluronidase-qvfc) (Harvard Pilgrim Stride)Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (Tufts Health Unify, Tufts Health Plan Senior Care Options, Tufts Medicare Preferred)		 Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Unify, Tufts Health Plan Senior Care Options, Tufts Medicare Preferred Dec. 1, 2023 Prior authorization will be required for Vyvgart Hytrulo (HCPCS J3590), approved in June 2023 for the treatment of generalized myasthenia gravis in adult patients who are anti-acetylcholine receptor antibody positive.
All products
Oct. 1, 2023
New MNG for Adstiladrin (HCPCS J9020), a non-replicating adenoviral vector-based gene therapy approved by the FDA in December 2022 to treat high-risk Bacillus Calmette-Guerin- unresponsive non-muscle invasive bladder cancer with carcinoma in situ with or without papillary tumors.
Prior authorization is required.
Columvi (glofitamab-gxbm) (Tufts Health Plan commercial, Tufts Health Direct)

Columvi (glofitamab-gxbm) (Tufts Health RITogether, Tufts Health Together)

Columvi (glofitamab-gxbm) (Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Unify)

 Tufts Health Plan commercial, Tufts Health Public Plans, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options Oct. 1, 2023 Prior authorization will be required for Columvi (HCPCS J9999), approved by the FDA in June 2023 for the treatment of diffuse large B-cell lymphoma not otherwise specified and large B-cell lymphoma resulting from follicular lymphoma for adults whose cancer has relapsed or become resistant to treatment after at least two previous rounds of systemic therapy.
Elfabrio (pegunigalsidase alfa-iwxj) (Harvard Pilgrim commercial)
Elfabrio (pegunigalsidase alfa-iwxj) (Tufts Health Plan commercial, Tufts Health Direct)
Elfabrio (pegunigalsidase alfa-iwxj) (Tufts Health RITogether, Tufts Health Together)
 Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Together Oct. 1, 2023 Prior authorization will be required for Elfabrio (HCPCS J3590), approved by the FDA in May 2023 for the treatment of Fabry disease.
Rystiggo (rozanolixizumab-noli) (Harvard Pilgrim commercial)
Rystiggo (rozanolixizumab-noli) (Harvard Pilgrim Stride)
All products
 Oct. 1, 2023 Prior authorization will be required for Rystiggo (HCPCS J3590), approved by the FDA in June 2023 for the treatment of generalized myasthenia gravis in adults who are anti-acetylcholine receptor- or anti-muscle-specific tyrosine kinase antibody-positive.
Vyvgart Hytrulo
(efgartigimod alfa and hyaluronidase-qvfc) (Harvard Pilgrim commercial)
Vyvgart Hytrulo
 Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether Oct. 1, 2023 Prior authorization is now required for Vyvgart Hytrulo (HCPCS J3590), approved in June 2023 for the treatment of generalized myasthenia gravis in adult patients who are anti-acetylcholine receptor antibody positive.
Antipsychotic Medications (Tufts Health RITogether)

Abilify Asimtufii
(aripiprazole) (Tufts Health Together)

 Tufts Health RITogether, Tufts Health Together Oct. 1, 2023 Prior authorization is now required for Abilify Asimtufii (HCPCS C9152), approved in April 2023 for the treatment of schizophrenia in adults and as maintenance monotherapy treatment of bipolar I disorder in adults.
Brixadi
(buprenorphine)		 Tufts Health RITogether Oct. 1, 2023 Prior authorization is now required for Brixadi (HCPCS J3490), approved in May 2023 for the treatment of moderate to severe opioid use disorder in patients who have initiated treatment with a single dose of a transmucosal buprenorphine product or who are already being treated with buprenorphine.
Uzedy
(risperidone)		 Tufts Health RITogether Oct. 1, 2023 Prior authorization is now required for Uzedy (HCPCS C9158), approved in April 2023 for the treatment of schizophrenia in adults.

Updates to existing prior authorization programs

Drug Plan Eff. date Policy & Additional Information
Myobloc
(rimabotulinumtoxin B)		 Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Unify, Tufts Health Plan Senior Care Options, Tufts Medicare Preferred Jan. 1, 2024 Myobloc (Harvard Pilgrim)

Myobloc (Tufts Health Plan)
Dysport
(abobotulinumtoxin A)		 Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Unify, Tufts Health Plan Senior Care Options, Tufts Medicare Preferred Jan. 1, 2024 Dysport (Harvard Pilgrim)

Dysport (Tufts Health Plan)
Evenity
(romosozumab-aqqg)		 Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Unify, Tufts Health Plan Senior Care Options, Tufts Medicare Preferred Jan. 1, 2024 Evenity (Harvard Pilgrim)

Evenity (Tufts Health Plan)
Prolia
(denosumab)		 Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Unify, Tufts Health Plan Senior Care Options, Tufts Medicare Preferred Jan. 1, 2024 Prolia (Harvard Pilgrim)

Prolia (Tufts Health Plan)
Xgeva
(denosumab)		 Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Unify, Tufts Health Plan Senior Care Options, Tufts Medicare Preferred Jan. 1, 2024 Xgeva (Tufts Health Plan)

 

Xgeva (Harvard Pilgrim Stride)
Signifor LAR
(pasireotide)		 Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Unify Jan. 1, 2024 Somatostatin Analogs for Non-oncology Indications (Harvard Pilgrim)

Somatostatin Analogs for Non-oncology Indications (Tufts Health Plan)
Altuviiio 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 Unify Dec. 1, 2023 Altuviiio (Harvard Pilgrim commercial)

Altuviiio (Harvard Pilgrim Stride)

Altuviiio (Tufts Health Plan commercial, Tufts Health Direct)

Altuviiio (Tufts Health RITogether)

Altuviiio (Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Unify)
Hemlibra 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 Unify Dec. 1, 2023 Hemlibra (Harvard Pilgrim commercial)

Hemlibra (Harvard Pilgrim Stride)

Hemlibra (Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether)

Hemlibra (Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Unify)
Amvuttra (vutrisiran), Onpattro (patisiran) Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether Dec. 1, 2023 Amyloidosis Therapies (Harvard Pilgrim commercial)

Amyloidosis Therapies (Tufts Health Plan Commercial, Tufts Health Direct)

Amyloidosis Therapies (Tufts Health RITogether)
Benlysta Intravenous Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether Dec. 1, 2023 Benlysta Intravenous (Harvard Pilgrim commercial)

Benlysta Intravenous (Tufts Health Plan commercial, Tufts Health Direct)

Benlysta Intravenous (Tufts Health RITogether)
Ultomiris Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage Tufts Health Unify, Tufts Health Plan Senior Care Options, Tufts Medicare Preferred Dec. 1, 2023 Ultomiris (Harvard Pilgrim)

Ultomiris (Tufts Health Plan)
Soliris Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Unify, Tufts Health Plan Senior Care Options, Tufts Medicare Preferred Dec. 1, 2023 Soliris (Harvard Pilgrim)

Soliris (Tufts Health Plan)
Vyvgart Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Unify, Tufts Health Plan Senior Care Options, Tufts Medicare Preferred Dec. 1, 2023 Vyvgart and Vyvgart Hytrulo (Harvard Pilgrim)

Vyvgart and Vyvgart Hytrulo (Tufts Health Plan)
Fabrazyme
(agalsidase beta)		 Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether Dec. 1, 2023 Fabrazyme (Harvard Pilgrim)

Fabrazyme (Tufts Health Plan)
Paclitaxel Protein Bound (Abraxane) Harvard Pilgrim commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage Dec. 1, 2023 Paclitaxel Protein Bound (Abraxane)
Advate, Adynovate, Afstyla, Alphanate, Alphanine, Alprolix, Benefix, Coagadex, Corifact, Eloctate, Esperoct, Feiba, Hemofil, Humate-P, Idelvion, Ixinity, Jivi, Koate, Kovaltry, Monoclate, Mononine, Novoeight, Novoseven, Nuwiq, Obizur, Profilnine, Rebinyn, Recombinate, Rixubis, Sevenfact, Tretten, Vonvendi, Wilate, Xyntha Harvard Pilgrim commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Medicare Preferred, Senior Care Options, Tufts Health Unify Dec. 1, 2023 Factor Products (Harvard Pilgrim)

Factor Products (Tufts Health Plan)
MassHealth Drug List Tufts Health Together Oct. 2, 2023 Minor criteria updates related to Zynteglo, a gene therapy treatment used to treat adult and pediatric beta-thalassemia patients who require regular red blood cell transfusions, as well as the chimeric antigen receptor (CAR) T-cell therapy drugs Abecma, Carvykti, Kymriah, and Tecartus

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