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 Commercial and Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage members. You can find information about this program on the OncoHealth page in the Vendor Programs section of the Harvard Pilgrim 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.
| Visit our new Medical Drug Medical Necessity Guidelines page to access these policies (unless otherwise noted). | |||
| New prior authorization programs | |||
| MNG/Drugs | Plan | Eff. date | Summary |
| Adzynma | Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | 4/1/2024 | Prior authorization is now required for Adzynma (HCPCS J3590, C9167), approved in November 2023 for the treatment of thrombotic thrombocytopenic purpura. |
| Lyfgenia (lovotibeglogene autotemcel) | Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether | 4/1/2024 | Prior authorization is now required for Lyfgenia, an autologous hematopoietic stem cell-based gene therapy approved by the FDA in December 2023 for the treatment of patients 12 years of age or older with sickle cell disease and a history of vaso-occlusive events. |
| Casgevy (exagamglogene autotemcel)
For Tufts Health Together criteria, refer to the MassHealth Drug List. |
Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether | 4/1/2024 | Prior authorization is now required for Casgevy, an autologous genome edited hematopoietic stem cell-based gene therapy approved by the FDA in December 2023 for the treatment of sickle cell disease (SCD) in patients 12 years and older with recurrent vaso-occlusive crises. |
| Targeted Immunomodulators Skilled Administration | Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | 4/1/2024 | Prior authorization is now required for Omvoh (HCPCS J3590), approved in September 2023 for the treatment of ulcerative colitis, and for Tofidence (HCPCS Q5133), approved in September 2023 for the treatment of rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, and systemic juvenile idiopathic arthritis. |
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Amondys 45 | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether | 6/1/2024 |
| Exondys 51 | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether | 6/1/2024 |
| Tzield (teplizumab-mzwv) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether | 6/1/2024 |
| Vyondys 53 | Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | 6/1/2024 |
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