The chart below identifies updates to our medical benefit drug program. For additional details, refer to the Medical Necessity Guidelines associated with the medical drug in question, which you can find on our Point32Health (the parent company of Harvard Pilgrim Health Care and Tufts Health Plan) Medical Benefit Drug Medical Necessity Guidelines page.
Alternatively, some medical drugs are managed through an arrangement with OncoHealth when utilized for oncology purposes for Harvard Pilgrim members. You can find information about this program on the OncoHealth page in the Vendor Programs section of Point32Health’s provider website and you can access the prior authorization policies for these drugs directly on OncoHealth’s webpage for Harvard Pilgrim.
Tufts Health Together utilizes MassHealth’s Unified Formulary for pharmacy medications and select medical benefit drugs; for drug coverage and criteria refer to the MassHealth Drug List.
Updates to existing prior authorization programs for OncoHealth drugs (for oncology purposes) For Harvard Pilgrim Health Care Commercial members | ||
| Drug/MNG | Additional information | Eff. date |
Gene Therapies for Sickle Cell Disease for RITogether
Lyfgenia
Casgevy | New medical drug MNG developed specific to Gene Therapies for Sickle Cell Disease for RITogether. Criteria for Lyfgenia (J3394) for Tufts Health RITogether has been removed from the Lyfgenia MNG for Commercial and Public Plans and can now be found on the new MNG. In addition, while criteria for Casgevy (J3392) will continue to be found on the Casgevy medical drug MNG for usage in treating beta thalassemia, the criteria for treating sickle cell disease with Casgevy has been moved to the new Gene Therapies for Sickle Cell Disease for RITogether MNG. Authorizations will be for 12 months and requests should be submitted directly to Point32Health. | 1/1/2026 |
| Eligard, Lupron Depot | Prior authorization is no longer required for HCPCS code J9217 (Leuprolide acetate [for depot suspension], 7.5 mg). | 12/1/2025 |
| Lupron Depot | Prior authorization is no longer required for HCPCS code J1950 (Injection, leuprolide acetate [for depot suspension], per 3.75 mg). | 12/1/2025 |