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.
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| MassHealth Drug List | Tufts Health Together
Prior authorization review for Lenmeldy will be performed using criteria from the MassHealth Drug List. |
10/1/2024 |
| Luxturna
|
Tufts Health Together
Criteria updated to require that the prescriber is a specialist (ophthalmologist or retinal specialist), and that the member has not received any prior gene therapy for biallelic RPE65. |
10/1/2024 |
| Elevidys
|
Tufts Health Together
Criteria updated to require that the member has not previously received treatment with a gene therapy for DMD, and that the infusion will take place in a qualified treatment facility.
|
10/1/2024 |
| Zolgensma
|
Tufts Health Together
Criteria updated to require that the member does not have active viral infection, including HIV or positive serology for hepatitis B or C, or Zika virus, and that the member has not previously received treatment with a gene therapy for spinal muscular atrophy. |
10/1/2024 |
| Vyjuvek | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Updated policy to specify that Vyjuvek will not be authorized in members who are currently on Filsuvez (birch triterpenes topical gel), as combination use with Vyjuvek and Filsuvez has not been studied. |
9/1/2024 |
| Breyanzi | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options
|
9/1/2024 |
| Casgevy | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Minor criteria language update. |
9/1/2024 |
| Luxturna | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct
Minor criteria revision. |
9/1/2024 |
| Zolgensma | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Annual review, no changes. |
9/1/2024 |
| Skysona | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Annual review, no changes. |
9/1/2024 |
| Elevidys | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Minor criteria updates. |
9/1/2024 |
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