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.
| New prior authorization programs | ||
| Drug/MNG | Plan & additional information | Eff. date |
| Ryoncil (remestemcel-L) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Ryoncil (J4302) is now covered with prior authorization for for the treatment of steroid-refractory acute graft versus host disease (SR-aGvHD) in pediatric patients 2 months of age and older. | 2/1/2026 |
| Encelto (revakinagene taroretcel-lwey) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Encelto (J3403) is now covered with prior authorization for the treatment of adults with idiopathic macular telangiectasia type 2 (MacTel). | 2/1/2026 |
| Updates to existing prior authorization programs | ||
| Drug/MNG | Plan & additional information | Eff. date |
| Elevidys (delandistrogene Moxeparvovec-rokl) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
In the August issue of Insights and Updates for Providers, Point32Health announced that we would no longer offer coverage of the gene therapy Elevidys for the treatment of Duchenne muscular dystrophy effective July 22, 2025 due to potential safety concerns announced by the U.S. Food and Drug Administration (FDA). We have since re-reviewed this medication according to updated FDA label recommendations, and we are resuming coverage of Elevidys (J1413) effective immediately with updated prior authorization criteria. | 2/1/2026 |
| Lenmeldy (atidarsagene autotemcel) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Minor revisions to criteria language. | 2/1/2026 |