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 for OncoHealth drugs (for oncology purposes) For Harvard Pilgrim Health Care Commercial and Tufts Medicare Preferred members | ||
| Drug/MNG | Plan & additional information | Eff. date |
| Rybrevant Faspro (amivantamab and hyaluronidase-lpuj) | Prior authorization is required for Rybrevant Faspro (HCPCS J9999). | 4/1/2026 |
| Boncresa (Denosumab-mobz) | Prior authorization is required for Boncresa (HCPCS J3590), a biosimilar to Prolia. | 4/1/2026 |
| Oziltus (Denosumab-mobz) | Prior authorization is required for Oziltus (HCPCS J3590), a biosimilar to Xgeva. | 4/1/2026 |
| New prior authorization programs | ||
| Drug/MNG | Plan & additional information | Eff. date |
| Kebilidi | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether Kebilidi (J3590), an adeno-associated virus (AAV) vector-based gene therapy indicated for the treatment of adult and pediatric patients with aromatic L-amino acid decarboxylase (AADC) deficiency, will be covered with prior authorization when the criteria identified on the MNG are met. | 4/1/2026 |
| Zevaskyn | Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care Point32Health will cover Zevaskyn (J3389), an autologous cell sheet-based gene therapy indicated for the treatment of wounds in adult and pediatric patients with recessive dystrophic epidermolysis bullosa, with prior authorization when the criteria on the MNG (which align with MassHealth’s criteria) have been met. | 4/1/2026 |
| Updates to existing prior authorization programs | ||
| Drug/MNG | Plan & additional information | Eff. date |
| Breyanzi | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether Language added to reflect that Breyanzi will be covered for the indication of marginal zone lymphoma (MZL) when the following criteria are met:
OR
| 4/1/2026 |
| HIV Pre-Exposure Prophylaxis (PrEP) Medications | Harvard Pilgrim Commercial, Tufts Health Plan Commercial Prior authorization is no longer required for the medication Apretude (HCPCS J0739). | 3/12/2026 |
| Gene Therapies for Sickle Cell Disease for RITogether | Tufts Health RITogether As we previously announced, we recently developed a medical drug MNG specific to Gene Therapies for Sickle Cell Disease for RITogethe which includes criteria for Lyfgenia (J3394) and Casgevy (J3392) for the treatment of sickle cell disease. Please be aware that the Rhode Island Executive Office of Health and Human Services (EOHHS) has developed a prior authorization form for gene therapies for sickle cell disease. When requesting authorization for a gene therapy to treat a Tufts Health RITogether member with sickle cell disease, please submit this form directly to Point32Health. A link to the form has been added to the RITogether MNG, and can also be found on the RI EOHHS Pharmacy Prior Authorization Program webpage. | 1/1/2026 |