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 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 |
| Pemetrexed (Apotex) | Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage
Prior authorization is now required (HCPCS code J9999). |
10/1/2024 |
| Rytelo | Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage
Prior authorization is now required (HCPCS code J9999). |
10/1/2024 |
| Docivyx | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J9999). |
10/1/2024 |
| Eribulin Mesylate | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J9999). |
10/1/2024 |
| Imdelltra | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J9999). |
10/1/2024 |
| New prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Durysta (bimatoprost intracameral implant)
Unified Medical Policies |
Tufts Health Together
Prior authorization will be required for Durysta (HCPCS J7351), approved by the FDA in March 2020 for the reduction of intraocular pressure in patients with open angle glaucoma or ocular hypertension. |
12/1/2024 |
| Omisirge (omidubicel-onlv)
|
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care
Omisirge (HCPCS J3590), which was approved by the FDA in April 2023 for the treatment of patients with hematologic malignancies, is now covered with prior authorization. Medicare Advantage/Senior Products (Harvard Pilgrim Stride, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care) will use MassHealth’s criteria for review. As a reminder, this coverage is already in place for Tufts Health Together, which uses the MassHealth Unified Formulary. |
10/1/2024 |
| Vyjuvek | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
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. |
10/1/2024 |
| Anktiva (nogapendekin alfa inbakicept-pmln) (Commercial and Public Plans)
Anktiva (nogapendekin alfa inbakicept-pmln) (Senior Products) |
Tufts Health RITogether, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Prior authorization is now required for Anktiva (HCPCS C9169), approved April 2024, for the treatment of adult patients with Bacillus Calmette-Guérin unresponsive nonmuscle invasive bladder cancer with carcinoma in situ with or without papillary tumors. |
10/1/2024 |
| Tyenne (tocilizumab-aazg)
Targeted Immunomodulators Skilled Administration (Commercial and Tufts Health Direct) Targeted Immunomodulators Skilled Administration (Tufts Health RITogether) Targeted Immunomodulators Skilled Administration (Senior Products) |
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Heath RITogether, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Prior authorization is now required for Tyenne (HCPCS Q5135), approved by the FDA in March 2024, for the treatment of adults with rheumatoid arthritis, adults with giant cell arteritis, patients at least 2 years of age with polyarticular juvenile idiopathic arthritis, and patients at least 2 years of age with systemic juvenile idiopathic arthritis. |
10/1/2024 |
| Kisunla (donanemab-azbt)
(Commercial, Public Plans, Tufts Health RITogether) |
Harvard Pilgrim Commercial, Tufts Health RITogether, Tufts Health Plan Commercial, Tufts Health Direct
Prior authorization is now required for Kisunla (HCPCS J0175), approved by the FDA in July 2024 for the treatment of Alzheimer’s disease. Treatment with Kisunla should be initiated in patients with mild cognitive impairment or mild dementia stage of disease, the population in which treatment was initiated in the clinical trials. |
10/1/2024 |
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Complement Inhibitors | Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 1/1/2025 |
| Evkeeza (evinacumab-dgnb) | Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 1/1/2025 |
| Leqvio (inclisiran) | Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 1/1/2025 |
| Rystiggo (rozanolixizumab-noll) | Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 1/1/2025 |
| Tepezza (teprotumumab-trbw) | Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 1/1/2025 |
| Vyvgart (efgartigimod alfa-fcab), Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) | Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 1/1/2025 |
| Givlaari (givosiran)
Givlaari |
Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Adding provider specialty requirements and updating diagnosis requirements. |
12/1/2024 |
| Remodulin (treprostinil)
Pulmonary Hypertension Medications |
Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct
Requests for brand name Remodulin will require documented failure of an adequate trial or inability to tolerate generic treprostinil. |
12/1/2024 |
| New to Market (NTM) Drugs | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
MNG name updated from New to Market (NTM) Drug Evaluation Process Under The Medical Benefit to New to Market (NTM) Drugs. Minor criteria update to add clarification related to gene therapies. |
10/1/2024 |
| Durolane, Euflexxa, Gel-One, Gel-Syn, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz, Synojoynt, Synvisc, Synvisc One, Triluron, Trivisc, and Visco-3
Unified Medical Policies |
Tufts Health Together
Viscosupplements will remain managed with prior authorization; however, effective for fill dates on or after Oct. 1, 2024, coverage criteria will be unified with MassHealth. As a result, all viscosupplements will now fall under the Unified Medical Policies MNG. |
10/1/2024 |
| Zolgensma | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct
Minor updates for consistency with criteria for other gene therapies. |
10/1/2024 |