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 for OncoHealth drugs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Palonosetron | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J2468). |
1/1/2025 |
| Pemetrexed | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J9292). |
1/1/2025 |
| New prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Complement Inhibitors – Medicare
Complement Inhibitors –Commercial, RITogether |
Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Prior authorization is now required for PiaSky (HCPCS J1307), approved by the FDA in June 2024 for the treatment of adult and pediatric patients 13 years and older with paroxysmal nocturnal hemoglobinuria and body weight of at least 40 kg. |
1/1/2025 |
| Kisunla
(donanemab-azbt) |
Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Prior authorization is now required for Kisunla (HCPCS J0175), approved by the FDA in July 2024 for the treatment of Alzheimer’s disease. |
1/1/2025 |
| Rytelo
(imetelstat)
|
Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Prior authorization is now required for Rytelo (HCPCS C9399, J3490), approved by the FDA in April 2024 for the treatment of adult patients with low- to intermediate-1 risk myelodysplastic syndromes with transfusion-dependent anemia requiring 4 or more red blood cell units over 8 weeks who have not responded to or have lost response to or are ineligible for erythropoiesis-stimulating agents. |
1/1/2025 |
| Tremfya (guselkumab) intravenous
Targeted Immunomodulators – Skilled Administration |
Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Prior authorization is now required for Tremfya IV (HCPCS J1628), approved by the FDA in September 2024 for the treatment of adult patients with moderately to severely active ulcerative colitis. |
1/1/2025
|
| Medicare Part B Step Therapy | Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Prior authorization is now required for Pavblu (HCPCS J3590), Nypozi (HCPCS C9173), and Hercessi (HCPC Q5146). These agents are non-preferred products within their respective therapeutic categories. |
1/1/2025 |
| Medical Benefit Step Therapy | Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together
Prior authorization is now required for Pavblu (HCPCS J3590), approved by FDA in August 2024 for neovascular (wet) age-related macular degeneration, macular edema following retinal vein occlusion, diabetic macular edema, and diabetic retinopathy. |
1/1/2025 |
| Trastuzumab Products | Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether
Prior authorization is now required for Hercessi (HCPCS Q5146), approved by the FDA approved in April 2024 for metastatic gastric cancer. Kanjinti and Trazimera are the preferred trastuzumab products and are available without prior authorization. |
1/1/2025 |
| Short-acting Colony Stimulating Factors | Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Prior authorization is now required for Nypozi (HCPCS C9173), approved in June 2024 for patients with cancer receiving myelosuppressive chemotherapy, patients with acute myeloid leukemia receiving induction or consolidation therapy, patients with cancer undergoing bone marrow transplantation, patients undergoing autologous peripheral blood progenitor cell collection and therapy, patients with severe chronic neutropenia, and acutely exposed to myelosuppressive doses of radiation (hematopoietic syndrome of acute radiation syndrome). Zarxio is the preferred Short-Acting Colony Stimulating Factor and does not require prior authorization. |
1/1/2025 |
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Abecma (idecabtagene vicleucel)
Breyanzi (lisocabtagene maraleucel) Carvykti (ciltacabtagene autoleucel) Kymriah (tisagenlecleucel) Tecartus (brexucabtagene autoleucel) Yescarta (axicabtagene ciloleucel) |
All products
We will no longer require prior authorization for harvesting, preparation, and administration of chimeric antigen receptor T-cell therapy medications. However, the medications themselves will continue to require prior authorization Refer to this article for more information. |
1/1/2025 |
| Lyfgenia
Casgevy Zynteglo Roctavian Hemgenix |
Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
We’ve incorporated criteria updates to align with MassHealth guidance and FDA labels. |
1/1/2025 |
| Casgevy
Lyfgenia |
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care
Minor criteria changes. |
1/1/2025 |
| Casgevy
Skysona |
Tufts Health Together
Criteria updated to reflect guidance from MassHealth, including adding criteria for treatment dependent beta thalassemia and adding a question pertaining to sickle cell disease. |
1/6/2025 |