Utilization Management for Pharmacy

Prior Authorization

In order to ensure safety and manage cost, Point32Health (and our Harvard Pilgrim Health Care and Tufts Health Plan legacy brands) requires prior authorization for certain drugs. Review our pharmacy medical necessity guidelines for information on drugs requiring prior authorization and our ways to request authorization page for  options for requesting authorization and forms.

For other products, please reference the prior authorization guidelines below:

Step Therapy

Step Therapy requires the use of certain preferred drugs to treat a medical condition before Point32Health will cover non-preferred drugs for that condition. Medications on Step 1—the lowest step—are usually covered without authorization. Medications on Step 2 or higher are automatically authorized at the point-of-sale if the member has taken the required pre­requisite drugs. However, if you prescribe a medication on a higher step, and the member has not yet taken the required medication(s) on a lower step, or if the member is a new member and does not have any prescription drug claims history, a request for coverage must be submitted to Point32Health.

View our formularies to see which drugs are included in our step therapy program.

You can also reference the step therapy guidelines for the below products:

Noncovered Drugs

There are thousands of drugs listed on Point32Health’s formularies. Most drugs are covered; however, there are some drugs that Harvard Pilgrim Health Care and Tufts Health Plan currently do not cover.

In many cases, these drugs are not covered because there are safe, comparably effective, and cost-effective alternatives available. Point32Health’s goal is to keep pharmacy benefits as affordable as possible.

Providers can submit a request for coverage under the Medical Review Process if a non-covered drugs is needed.

New-to-Market Evaluation

Point32Health requires that all drugs meet a series of high standards before they are included in our formularies. We understand it may be frustrating to discover a new drug isn’t yet covered, but we want you to know that it may be for a good reason.

Providers have the option to submit a coverage request for the new-to-market drugs while the drugs are under our new-to-market evaluation process.

Quantity Limitations

As with all the pharmacy programs, Point32Health has developed the Quantity Limitations Program in an effort to monitor safety and help control the cost of prescription drugs for members. This program limits the quantity of select drugs that a member can receive in a given time period.