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.

Updates to existing prior authorization programs
DrugPlanEff. datePolicy & additional information
Non-Formulary DrugsHarvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct1/1/2026

Non-Formulary Exceptions PMNG

  • Updated criteria related to non-formulary review of Wegovy for certain indications for the Value and Premium formularies.
  • Removed non-formulary coverage criteria for Zepbound in moderate to severe obstructive sleep apnea in obesity.
AjovyHarvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct1/1/2026

Non-Triptan Migraine Medications PMNG

Moved Ajovy to Non-Formulary; Prior Authorization