As we shared previously, 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. (As a reminder, Point32Health’s Tufts Health Plan Commercial line of business will no longer be offered as of Jan. 1, 2027, so future changes outlined below are applicable to Harvard Pilgrim Commercial and Tufts Health Direct members.)

These updates initially applied only to members initiating treatment on or after Jan. 1, 2026, and existing utilizers were not affected by the changes. However, due to new approval‑duration rules and the introduction of Reauthorization Criteria, certain members receiving a targeted immunomodulator for a dermatological indication were required or will soon be required to obtain reauthorization to maintain continued access to therapy. 

The implementation plan for this change was divided into 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 were terminated on June 30, 2026 for members who would have been utilizing their drug for greater than one year as of July 1, 2026. 

Additional members to be impacted on Dec. 31, 2026

For members who will have completed at least one year of utilization by Jan. 1, 2027, existing prior authorizations will terminate on Dec. 31, 2026.

If continued treatment is clinically appropriate, prescribers will need to submit a new prior authorization request beginning Jan. 1, 2027. These requests will be reviewed under the updated Reauthorization Criteria.

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 

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