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 Medical Benefit Drug Medical Necessity Guidelines page. Point32Health is the parent company of Harvard Pilgrim Health Care and Tufts Health Plan.
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 for OncoHealth drugs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Docivyx (docetaxel) | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J9999).
|
8/1/2024 |
| Generic eribulin mesylate | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J9999).
|
8/1/2024 |
| Imdelltra (tarlatamab-dlle) | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J9999).
|
8/1/2024 |
| Tevimbra | Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage
Prior authorization is now required (HCPCS code J9999). |
8/1/2024 |
| Medications being added to prior authorization | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Alyglo (immune globulin intravenous, human-stwk, 10% liquid)
Intravenous Immune Globulin (IVIG) and Subcutaneous Immune Globulin (SCIG) Products
|
Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct
Prior authorization will be required for members 18 years of age or older for Alyglo (HCPCS J1599), approved by the FDA in Dec. 2023 for the treatment of adults with primary humoral immunodeficiency.
|
10/1/2024 |
| Part B Step Therapy (will be available as of 10/1/2024)
Focinvez (fosaprepitant) |
Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Focinvez (HCPCS J1434) will be added to the Part B Step Therapy Policy as a non-preferred agent and will now require prior authorization. |
10/1/2024 |
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Part B Step Therapy (will be available as of 10/1/2024) | Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
|
10/1/2024 |
| Syfovre (pegcetacoplan) | Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 10/1/2024 |
| Xgeva (denosumab) | Tufts Health RITogether, Tufts Health Plan Commercial, Tufts Health Direct | 10/1/2024 |
| Prolia (denosumab) | Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 10/1/2024 |
| Amtagvi | Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options
Point32Health will now use MassHealth criteria for prior authorization review of Amtagvi. |
9/1/2024 |
| Leqembi (lecanemab-irmb)
Unified Medical Policies |
Tufts Health Together
Coverage criteria for Leqembi will now be unified with MassHealth. |
8/14/2024 |
*Editor’s note: 9/27/2024 — removed Harvard Pilgrim Commercial from the list of applicable products for the change regarding Focinvez (HCPCS J1434) and the Part B Step Therapy MNG.
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