As we announced in the November 2025 issue of Insights and Updates for Providers, on Jan. 1, 2026 Point32Health implemented extensive updates to coverage criteria and prior authorization requirements for targeted immunomodulator medications across the Pharmacy and Medical benefits for Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, and Tufts Health Direct.

These updates initially applied only to members initiating treatment on or after Jan. 1, and existing utilizers were not affected by the changes. However, members who are currently receiving a targeted immunomodulator for a dermatological indication will soon be required to obtain reauthorization to maintain continued access to therapy.

We’re implementing this change in two phases, based on the length of time the member has been utilizing the medication. Existing prior authorizations for members using a targeted immunomodulator therapy to treat hidradenitis suppurativa, plaque psoriasis, or psoriatic arthritis will terminate at 11:59 p.m. on the dates below:

  • June 30, 2026 — members who will have been utilizing their drug for greater than one year as of July 1, 2026.
  • Dec. 31, 2026  — members who will have completed at least one year of utilization by Jan. 1, 2027. 

If continued treatment is clinically appropriate, prescribing providers will need to submit a reauthorization request demonstrating that the member continues to meet Point32Health’s updated medical necessity and clinical criteria. (Prescribers will receive letters well in advance of the respective termination dates outlining their impacted patients and which drug/s they will need reauthorized.)

Requesting authorization

We encourage you to submit requests for reauthorization via PromptPA for ease and efficiency. Alternatively, you may submit requests using one of the standard authorization processes outlined on our provider website. Reauthorization submissions should include all required clinical documentation, including but not limited to diagnosis, treatment response, and ongoing need for therapy.

More information

These updates are intended to support the safe and efficacious use of targeted immunomodulator medications.

Detailed authorization criteria and submission requirements are available in our Pharmacy Medical Necessity Guidelines and Medical Benefit Drug Medical Necessity Guidelines.