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 |
Zevaskyn MassHealth Adjudicated Payment Amount per Discharge and Adjudicated Payment per Episode Carve Out Drugs | Tufts Health Together For Together members, prior authorization for Zevaskyn (J3590) will be required via the MassHealth Unified Formulary. Coverage and prior authorization criteria will be available on the MassHealth Drug List and our MassHealth Adjudicated Payment Amount per Discharge and Adjudicated Payment per Episode Carve Out Drugs MNG for Tufts Health Together. | 11/17/2025 |
Enflonsia Unified Medical Policies | Tufts Health Together In alignment with MassHealth, we will cover Enflonsia, a monoclonal antibody vaccine approved by the FDA in June 2025 for the prevention of respiratory syncytial virus (RSV) in newborns and infants entering their first RSV season. Prior authorization is required for members ≥8 months of age, and criteria can be found on our Unified Medical Policies MNG. | 11/17/2025 |
Qfitlia Unified Medical Policies | Tufts Health Together In alignment with MassHealth, we will cover Qfitlia, approved by the FDA in March 2025 for routine prophylaxis to prevent or reduce the frequency of bleeding episodes in adult and pediatric patients 12 years of age and older with hemophilia A or hemophilia B Prior authorization criteria can be found on our Unified Medical Policies MNG. | 11/17/2025 |
Yeztugo Unified Medical Policies | Tufts Health Together In alignment with MassHealth, we will cover Yeztugo, an injectable HIV-1 capsid inhibitor approved by the FDA in June 2025 as pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV. Prior authorization criteria can be found on our Unified Medical Policies MNG. | 11/17/2025 |
| Updates to existing prior authorization programs | ||
| Drug/MNG | Plan & additional information | Eff. date |
Vyjuvek Unified Medical Policies | Tufts Health Together In accordance with a MassHealth criteria update, we’re adding information to clarify that Vyjuvek will not be used on the same target wounds as other topicals or gene therapies for a diagnosis of DEB, e.g., Filsuvez or Zevaskyn. Coverage and prior authorization criteria will be available on the MassHealth Drug List and our Unified Medical Policies MNG for Tufts Health Together. | 11/17/2025 |
| Vyjuvek | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
| 11/1/2025 |