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

Asmanex HFA

Asmanex Twisthaler

Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct1/1/2026

Asmanex Step Therapy policy

Updated step therapy program to remove Pulmicort Flexhaler.

Fluticasone propionate HFA Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct1/1/2026

Fluticasone propionate HFA Step Therapy Program policy

Updated step therapy program to remove Pulmicort Flexhaler.

Wegovy 

 

Zepbound

Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct1/1/2026

Non-Formulary Exceptions policy

  • Clarified that non-formulary review of Wegovy for secondary cardiovascular prevention in overweight/obesity or metabolic dysfunction-associated steatohepatitis (MASH) is applicable to only Value and Premium formularies.
  • Updated Wegovy’s non-formulary criteria for secondary cardiovascular prevention in overweight/obesity to exclude type 1 diabetes.
  • Removed non-formulary coverage criteria for Zepbound in moderate to severe obstructive sleep apnea in obesity.
Zepbound (tirzepatide)Harvard Pilgrim Commercial, Tufts Health Plan Commercial1/1/2026

Weight Loss Medications policy

  • Updated initial criteria for Zepbound to require that the patient has successfully completed 6 months of the plan-specified behavior modification program, if applicable. 

2026 drug status and formulary updates

Please refer to this document to review drug status and formulary changes for Harvard Pilgrim Commercial, Tufts Health Plan Commercial, and Tufts Health Direct for the 2026 plan year, including:

  • Drugs moving to non-formulary status
  • Drugs moving to a higher tier
  • Drugs moving to excluded status
  • Drugs with prior authorization added

2026 drug status and formulary updates for Tufts Health RITogether, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, and Tufts Health One Care will be announced in the November issue of Insights and Updates for Providers.