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
|
| Datroway (Datopotamab deruxtecan-dlnk) | Harvard Pilgrim Commercial
Prior authorization is required for coverage of Datroway (HCPCS J9999) for use in patients with previously treated metastatic HR-positive, HER2-negative breast cancer. |
3/1/2025 |