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 members | ||
MNG/Drug(s) | Additional information | Eff. date |
Avtozma (tocilizumab-anoh) | Avtozma (tocilizumab-anoh) (Q5156), a biosimilar of Actemra (tocilizumab), will be covered with prior authorization. | 11/1/2025 |
Tocilizumab Fresenius (tocilizumab-aazg) | Tocilizumab Fresenius (tocilizumab-aazg) (J9999), a generic biosimilar to Tyenne (tocilizumab-aazg), approved by the FDA in March 2024, will be covered with prior authorization. Please note that only the IV formulation of the drug will be covered.
| 11/1/2025 |
Tocilizumab Celltrion (tocilizumab-anoh) | Tocilizumab Celltrion (tocilizumab-anoh) (J9999), a generic biosimilar of Avtozma (tocilizumab-anoh), approved by the FDA in January 2025, will be covered with prior authorization. Please note that only the IV formulation of the drug will be covered.
| 11/1/2025 |
New prior authorization programs | ||
Drug/MNG | Plan & additional information | Eff. date |
Kebilidi | Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care Prior authorization is now required for Kebilidi, an adeno-associated virus vector-based gene therapy indicated for the treatment of adult and pediatric patients with aromatic L-amino acid decarboxylase deficiency. Our coverage criteria are aligned with MassHealth’s, as is the case for all gene therapies for our Senior Products. | 10/1/2025 |
Encelto MassHealth Adjudicated Payment Amount per Discharge and Adjudicated Payment per Episode Carve Out Drug | Tufts Health Together, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care The ophthalmology drug Encelto (J3403) is covered with prior authorization. | 10/1/2025 |
>Ryoncil Unified Medical Policies | Tufts Health Together Ryoncil (J3402) is covered with prior authorization. | 10/1/2025 |
Updates to existing prior authorization programs | ||
Drug/MNG | Plan & additional information | Eff. date |
Luxturna | Tufts Health Together Criteria updated to remove the following:
Luxturna monitoring program | 10/1/2025 |
Abecma Breyanzi Carvykti Kymriah Tecartus Yescarta | Tufts Health Together Criteria updated to remove authorized treatment center requirements for these T-cell immunotherapies. | 10/1/2025 |