Updates to Medical Necessity Guidelines (MNG)
| MNG Title | Products Affected Effective | Date | Summary |
| Genetic Testing: BRCA1, BRCA2, Hereditary Breast, Ovarian, and Pancreatic Cancer | Tufts Health Plan commercial | Sept. 1, 2023 | Prior authorization will be required for CPT codes 81432, 81433, and 0129U. |
| Tepezza (Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether)
Tepezza (Tufts Health Together) Tepezza (Tufts Medicare Preferred, Tufts Health Plan SCO, Tufts Health Unify) Tepezza (Harvard Pilgrim commercial Tepezza (Harvard Pilgrim Stride) |
Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage, Tufts Health Plan commercial, Tufts Health Together, Tufts Health Direct, Tufts Health RITogether, Tufts Health Plan Senior Products, Tufts Health Unify | Sept. 1, 2023 | Prior authorization will be required for Tepezza (HCPCS J3241) for Harvard Pilgrim Stride.
For all applicable products, criteria expanded to reflect FDA guidance. |
| Opdualag (Harvard Pilgrim commercial: see OncoHealth site)
Opdualag (Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether) Opdualag (Tufts Health Together) Opdualag (Tufts Medicare Preferred, Tufts Health Plan SCO, Tufts Health Unify) |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans, Tufts Health Plan Senior Products | Sept. 1, 2023 for Tufts Health Plan Senior Products; July 1, 2023 for all other applicable lines of business.
|
Prior authorization will be required for Tufts Health Plan Senior Products.
In alignment with OncoHealth criteria and guidance from the National Comprehensive Cancer Network, Tufts Health Plan initial approval criteria no longer require that the patient first try Keytruda and Opdivo before being eligible for coverage of Opdualag. For Harvard Pilgrim, initial approval criteria no longer require that the patient first try Keytruda, Opdivo, and/or combination therapy with Opdivo and Yervoy. |
| Outpatient Rehabilitative Services: Occupational Therapy
Habilitative Services for Physical Therapy, Occupational Therapy and Speech Therapy |
Tufts Health Plan commercial, Tufts Health Direct | July 1, 2023 | Removed limitation applied to occupational therapy treatment programs for children with attention deficit hyperactivity disorder (e.g., skill-enhancing training such as motor-perceptual training, cognitive-perceptual training, handwriting training, self-care training, and social skills training). These treatment programs are now covered with prior authorization. |
| Community Support Programs including Specialized Community Support Programs | Tufts Health Together, Tufts Health Plan Senior Care Options | July 1, 2023 | New comprehensive coverage guideline outlining criteria from MassHealth. Notification will continue to be required for the services on the MNG, and prior authorization is not required. |
| Altuviiio (Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether)
Altuviiio (Tufts Medicare Preferred, Tufts Health Plan SCO, Tufts Health Unify) Aultuviiio (Harvard Pilgrim commercial) Altuviiio (Harvard Pilgrim Stride) |
Harvard Pilgrim commercial, Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Plan Senior Products, Tufts Health Unify | July 1, 2023 | Prior authorization now required for Altuviiio (HCPCS J3490), approved by the FDA in February 2023 for the treatment of hemophilia A. |
| Botulinum Toxins (Harvard Pilgrim commercial)
Botulinum Toxins (Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether) |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether | July 1, 2023 | Criteria for Botox (HCPCS J0585) for the treatment of overactive bladder broadened to allow for Botox to be prescribed by a urologist or a urogynecologist. |
| Lamzede (Harvard Pilgrim commercial)
Lamzede (Harvard Pilgrim Stride) Lamzede (Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether) Lamzede (Tufts Medicare Preferred, Tufts Health Plan SCO, Tufts Health Unify) |
Harvard Pilgrim commercial, Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Plan Senior Products, Tufts Health Unify | July 1, 2023 | Prior authorization now required for Lamzede (HCPCS J3490), approved in February 2023 for the treatment of non-central nervous system manifestations of alpha-mannosidosis. |
| Retinal Disorders (Harvard Pilgrim Stride)
Retinal Disorders (Tufts Medicare Preferred, Tufts Health Plan SCO, Tufts Health Unify) |
Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage, Tufts Health Unify, Tufts Health Senior Products
|
July 1, 2023 | One overarching MNG has been developed for Retinal Disorders. The following individual drug policies have been retired, and their criteria (which have not changed) can now be found on the overarching MNG for this drug class:
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| OncoHealth HPHC Chemotherapy HCPCS J-Codes List | Harvard Pilgrim commercial, Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage | July 1, 2023 | Prior authorization now required for Zynyz (HCPCS J3490), approved by the FDA in March 2023 for adult patients with metastatic or recurrent locally advanced Merkel cell carcinoma (MCC). |
| Briumvi | Tufts Health Together | July 1, 2023 | New MNGs for Briumvi (J2399), Furoscix (J1941), and Sunlenca (J1961). These MNGs will be in effect from July 1, 2023 to July 31, 2023, at which point the MNGs will be retired and the drugs will be managed using MassHealth Unified Formulary criteria for Tufts Health Together members. The criteria on the temporary Tufts Health Together MNGs will mirror MassHealth’s criteria. Refer to the article titled “MassHealth Unified Formulary updates” in this issue for more information. |
| Medicare Part B Step Therapy (Tufts Medicare Preferred, Tufts Health Plan SCO, Tufts Health Unify)
Medicare Part B Step Therapy (Harvard Pilgrim Stride) |
Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Unify, Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage | July 1, 2023 | Vivimusta (HCPCS J9506), a drug in the Bendamustine HCI injection class used to treat chronic lymphocytic leukemia, has been added as a non-preferred product and now requires prior authorization. Generic Bendamustine HCI (HCPCS J9033) has been added as a preferred products and does not require prior authorization. |
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