Effective Jan. 1, 2026, Point32Health is making extensive updates to criteria and requirements associated with our Pharmacy and Medical benefit prior authorization programs pertaining to targeted immunomodulator medications for Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, and Tufts Health Direct. 

These updates — which will apply to members initiating treatment on or after Jan. 1 — have been incorporated consistently across Pharmacy and Medical Benefit Medical Necessity Guidelines, as applicable (see below for a list of impacted guidelines), and are intended to further align our prior authorization programs and policies with industry guidance and encourage the safe and efficacious use of targeted immunomodulator medications. 

Updates include:

  • Diagnosis requirements aligned with Food and Drug Administration approved indication
  • Provider specialty requirements will no longer include “in consultation with” language
  • Language acknowledging stability on the requested medication for patients new to the plan has been removed. Documentation of stability provided on a prior authorization or non-formulary exception request will be taken into consideration as part of the medical necessity review process.
  • Addition of a step through a Tumor Necrosis Factor (TNF) inhibitor for Janus Kinase (JAK) inhibitors, for shared indications, in line with FDA-approved package labeling and boxed warnings.
  • Implementation of differentiated approval durations based on therapeutic area. For dermatological indications, initial authorizations will be approved for six months and reauthorization approvals will be approved for 12 months. For non-dermatological indications, initial authorizations and reauthorizations will be approved for 12 months. Due to the new approval durations, specific reauthorization criteria will now apply.
  • Addition of language to prevent duplicative targeted immunomodulator therapy. Current data offers minimal support for the efficacy and safety of duplicative therapy.
  • Addition of minimum duration requirements to pre-requisites for select scenarios to ensure appropriate use of targeted immunomodulators.
  • Addition of specific clinical criteria confirming moderate to severe disease for plaque psoriasis, active psoriatic arthritis, and moderate to severe hidradenitis suppurativa.
  • Addition of language to support documentation of prerequisite trials.
  • For non-preferred targeted immunomodulators indicated for plaque psoriasis and psoriatic arthritis, updated non-biologic prerequisites.

For additional details and to access the guidelines referenced below, please visit the Pharmacy Medical Necessity Guidelines page and Medical Benefit Drug Medical Necessity Guidelines page on our Point32Health provider website.

Impacted guidelines include:

  • Actemra (tocilizumab)
  • Adalimumab products
  • Adbry (tralokinumab-ldrm)
  • Bimzelx (bimekizumab-bkzx)
  • Cibinqo (abrocitinib)
  • Cimzia (certolizumab pegol)
  • Cosentyx (secukinumab)
  • Dupixent (dupilumab)
  • Ebglyss (lebrikizumab-lbkz)
  • Enbrel (etanercept)
  • Entyvio (vedolizumab)
  • Humira (adalimumab)
  • Kevzara (sarilumab)
  • Kineret (anakinra)
  • Litfulo (ritlectinib tosylate)
  • Nemluvio (nemolizumab-ilto)
  • Olumiant (baricitinib)
  • Omvoh (mirikizumab-mrkz)
  • Orencia (abatacept)
  • Otezla (apremilast)
  • Rinvoq (upadacitinib)
  • Siliq (brodalumab)
  • Simponi (golimumab)
  • Skyrizi (risankizumab-rzaa)
  • Sotyktu (deucravacitinib)
  • Spevigo (spesolimab-sbzo) – Pharmacy and Medical Medical Necessity Guideline
  • Taltz (ixekizumab)
  • Targeted Immunomodulator Skilled Administration
  • Tocilizumab Products
  • Tremfya (guselkumab)
  • Ustekinumab Products
  • Velsipity (etrasimod arginine)
  • Xeljanz (tofacitinib citrate)
  • Yesintek (ustekinumab-kfce)
  • Zeposia (ozanimod)
  • Zymfentra (infliximab-dyyb)