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 | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Imaavy (nipocalimab) | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether Added documentation of Myasthenia Gravis Foundation of America (MGFA) Clinical Classification Class II to IV generalized myasthenia gravis, Myasthenia Gravis-Activities of Daily Living (MG-ADL) total score of at least 6, and updated requirements to establish refractory disease of generalized myasthenia gravis. | 10/1/2026 |
| Medical Benefit Step Therapy | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Direct
Added Vykoura to the MNG. | 10/1/2026 |
| Targeted Immunomodulators Skilled Administration | Tufts Health RITogether Starjemza (ustekinumab-hmny) added to the MNG and will be the preferred ustekinumab product. Coverage of Yesintek will require documentation of trial and failure with Starjemza, or clinical rationale for continuation of treatment with Yesintek. | 10/1/2026 |
| Adstiladrin | Harvard Pilgrim Commercial, Tufts Medicare Preferred Prior authorization for Adstiladrin (J9029) will managed through our arrangement with OncoHealth. | 10/1/2026 |
| Epioxa | Harvard Pilgrim Commercial Epioxa (J2789) is currently covered with prior authorization for the treatment of keratoconus, and the prior authorization criteria can be found in the Epioxa MNG. Effective for dates of service beginning Oct. 1, 2026, however, prior authorization will no longer be required. Epioxa will be covered without authorization only when a diagnosis of keratoconus is present. | 10/1/2026 |
Vyjuvek (Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether)
Vyjuvek (Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan SCO)
| Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care, Tufts Health Medicare Preferred, Tufts Health Plan SCO MNG updated to remove age restriction. Vyjuvek (J3401) will now be covered for adult and pediatric members of all ages with a diagnosis of dystrophic epidermolysis bullosa when all criteria are met. | 8/1/2026 |
| Zolgensma | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether Criteria updated to specify that Zolgensma (J3399) will be covered only when documentation confirms that the member has not received a previous gene therapy for spinal muscular atrophy (including Zolgensma or Itvisma). With the approval of Itvisma, there are two spinal muscular atrophy gene therapies now, and as such, we need to address not having either/or before. | 8/1/2026 |