Pharmacy coverage changes

The chart below identifies updates for Pharmacy Medical Necessity Guidelines. For additional details and to access the guidelines referenced below, please visit the Pharmacy Medical Necessity Guidelines page on our Point32Health provider website.

Drug status changes
Drug	Plan	Eff. date	Policy & additional information
Imcivree	Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether	5/1/26	Imcivree PMNG Updated coverage criteria to include requirement that medication is prescribed specifically by an endocrinologist, geneticist, or physician who specializes in metabolic disorders.
Bydureon BCise Byetta Mounjaro Ozempic Rybelsus Trulicity	Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct	5/1/26	Incretin Mimetics PMNG Removed step therapy coverage criteria (including automated step therapy coverage criteria) for formularies subject to step therapy program, as these formularies will be subject to prior authorization. Updates apply to Premium, Value, Select, Core MA, Direct, and ConnectorCare formularies.
Insulin and Diabetes Supplies	Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct	5/1/26	Insulin and Diabetes Supplies PMNG Updated limitation section to include non-formulary product initial and reauthorization approval durations.
Growth Hormones	Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct	5/1/26	Growth Hormones PMNG Updated limitations section to clarify approval duration for non-formulary products due to shortage.

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Pharmacy coverage changes