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 |
| Zevaskyn | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether New medical drug MNG for Zevaskyn (J3389), which will be covered with prior authorization for the treatment of recessive epidermolysis bullosa. | 11/1/2026 |
Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
Cinryze (C1 esterase inhibitor)
| Harvard Pilgrim Commercial, Tufts Health Direct, Tufts Health RITogether Added diagnostic criteria for hereditary angioedema. | 1/1/2027
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| Complement Inhibitors | Harvard Pilgrim Commercial, Tufts Health Direct
Rystiggo and Vyvgart/Vyvgart Hytrulo will be designated as the preferred products for the diagnosis of generalized myasthenia gravis. Patients with this diagnosis will be required to step through one of these medications before receiving coverage for another medication. Similiarly, Epysqli will become the preferred eculizumab product, and patients will need to step through Epysqli before coverage will be granted for Bkemv, Soliris and Ultomiris for shared indications. | 1/1/2027 |
| Imaavy | Harvard Pilgrim Commercial, Tufts Health Direct Step through Rystiggo or Vyvgart/Vyvgart Hytrulo will be required for the diagnosis of generalized myasthenia gravis. Additionally, prior authorization criteria added for the diagnosis of warm autoimmune hemolytic anemia. | 1/1/2027 |
| New-to-Market Medical Benefit Drugs | Harvard Pilgrim Commercial, Tufts Health Direct Updated exception criteria for new-to-market medical benefit drugs | 1/1/2027 |
| Uplizna | Harvard Pilgrim Commercial, Tufts Health Direct Step through Rystiggo or Vyvgart/Vyvgart Hytrulo will be required for the diagnosis of generalized myasthenia gravis. | 1/1/2027 |
| Complement Inhibitors | Tufts Health RITogether Step through Epysqli will be required for Bkemv, Soliris and Ultomiris for shared indications. | 1/1/2027 |
| Targeted Immunomodulators Skilled Administration | Tufts Health RITogether Step through Avtozma will be required for Actemra, Tofidence, and Tyenne | 1/1/2027 |
| Medicare Part B Step Therapy | Tufts Medicare Preferred, Tufts Health Plan SCO, Tufts Health One Care Added a second step to obtain non-preferred denosumab products. Stoboclo, Osenvelt, Bildyos, Biprevda, Enoby, and Xtrenbo will be step-2 (or preferred products within the denosumab product line) Created new categories under Rare Disease for Atypical hemolytic uremic syndrome (aHUS), neuromyelitis optica spectrum disorder (NMOSD), Biopsy Proven Dense Deposit Disease, paroxysmal nocturnal hemoglobinuria (PNH), and generalized myasthenia gravis (gMG).
| 1/1/2027 |
| Casgevy | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Medicare Preferred, Tufts Health Plan SCO, Tufts Health One Care Expanding the age limit specified on the policy to include ages 2+ who are at least 12 kg in weight. This applies to both indications, Sickle Cell Disease and Beta Thalassemia. | 11/1/2026 |
Otarmeni
| Tufts Health Together New MassHealth Carve-Out Drug indicated for the treatment of severe-to-profound and profound sensorineural hearing loss (any frequency > 90dB HL) associated with molecularly confirmed biallelic variants in the otoferlin gene, preserved outer hair cell function, and no prior cochlear implant in the same ear. Prior authorization is required, and providers should bill code J3590. | 11/16/2026 |
| Breyanzi | Tufts Medicare Preferred, Tufts Health Plan SCO, Tufts Health One Care Addition of Marginal Zone Lymphoma as an approved indication, with the following prior authorization/coverage criteria:
| 11/1/2026 |
| Omisigre | Tufts Medicare Preferred, Tufts Health Plan SCO, Tufts Health One Care Prior authorization will be required for Omisigre (code J3406). In addition, criteria updated, to include Severe Aplastic Anemia as an approved indication. Additional language added regarding treatment centers with expertise in stem cell transplant. | 11/1/2026 |