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 | ||
| Drug/MNG | Plan & additional information | Eff. date |
| Keytruda Qlex | Prior authorization is required for coverage of Keytruda Qlex (HCPCS J9999). | 12/1/2025 |
| Inlexzo | Prior authorization is required for coverage of Inlexzo (HCPCS J9999). | 12/1/2025 |
| Papzimeos | Prior authorization is required for coverage of Papzimeos (HCPCS J9999). | 12/1/2025 |
| Bildyos | Prior authorization is required for coverage of Bildyos (HCPCS J3590), a biosimilar to Xgeva. | 12/1/2025 |
| Bilprevda | Prior authorization is required for coverage of Bilprevda (HCPCS J3590), a biosimilar to Xgeva. | 12/1/2025 |
| Bosaya | Prior authorization is required for coverage of Bosaya (HCPCS J3590), a biosimilar to Prolia. | 12/1/2025 |
| Aukelso | Prior authorization is required for coverage of Aukelso (HCPCS J3590), a biosimilar to Xgeva. | 12/1/2025 |
| Enoby | Prior authorization is required for coverage of Enoby (HCPCS J3590), a biosimilar to Prolia. | 12/1/2025 |
| Xtrenbo | Prior authorization is required for coverage of Xtrenbo (HCPCS J3590), a biosimilar to Prolia. | 12/1/2025 |
| Qivigy | Prior authorization is required for coverage of Qivigy (HCPCS J1599). | 12/1/2025 |
| Blenrep | Prior authorization is required for coverage of Blenrep (HCPCS J9999). | 12/1/2025 |
| Zusduri | Prior authorization is required for coverage of Zusduri (HCPCS J9999). | 12/1/2025 |
| Updates to existing prior authorization programs | ||
| Drug/MNG | Plan & additional information | Eff. date |
| Vyjuvek | Tufts Health One Care (HMO D-SNP), Tufts Medicare Preferred, Tufts Health Plan Senior Care Options In alignment with MassHealth criteria, we’ve updated the limitations section on the MNG to specify 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. | 12/1/2025 |