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 | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Itvisma | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether Prior authorization is now required for Itvisma (onasemnogene abeparvovec-brve) (HCPCS J3405), an adeno-associated virus vector-based gene therapy indicated for the treatment of spinal muscular atrophy. | 7/1/2026 |
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Respiratory Interleukins: Cinqair, Fasenra, Nucala | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct Changes include, but are not limited to, increased emphasis on chart-confirmed diagnosis and response to therapy, increased emphasis on disease severity, more explicit concurrent therapy requirements, clearer separation of failure of treatment alternatives vs requested use as add-on therapy, standardization of minimum treatment durations of non-biologic therapies, and standardization of duration of approval rules. | 9/1/2026 |
Tezspire (tezepelumab-ekko)
| Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct Changes include, but are not limited to, increased emphasis on chart-confirmed diagnosis and response to therapy, increased emphasis on disease severity, more explicit concurrent therapy requirements, clearer separation of failure of treatment alternatives vs requested use as add-on therapy, and standardization of minimum treatment durations of non-biologic therapies. | 9/1/2026 |
| Xolair (omalizumab) | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct Changes include, but are not limited to, increased emphasis on chart-confirmed diagnosis and response to therapy, increased emphasis on disease severity, more explicit concurrent therapy requirements, clearer separation of failure of treatment alternatives vs requested use as add-on therapy, standardization of minimum treatment durations of non-biologic therapies, and standardization of duration of duration of approval rules. | 9/1/2026 |
Elevidys | Tufts Health Together Coverage expanded for Elevidys, with new criteria for coverage in patients over six years old. | 7/1/2026 |
| MassHealth Acute Hospital Carve-Out Drug List | Beqvez and Roctavian removed from guidelines, as these medications have been removed from the market. | 7/1/2026 |