Medical Benefit Drug Medical Necessity Guidelines

The Medical Drug Medical Necessity Guidelines below detail coverage criteria for medical benefit drugs for Harvard Pilgrim Health Care and Tufts Health Plan lines of business. We encourage you to use the drop-down menu to filter applicability by product. We note line of business under the guideline name; however, the policy may not apply to every product in that line of business. Please refer to the policy for product applicability.

Tufts Health Together utilizes MassHealth’s Unified Formulary for pharmacy medications and select medical benefit drugs. For a list of medical benefit medications that utilize MassHealth coverage criteria, refer to the Unified Medical Policies Medical Necessity Guidelines, and for the MassHealth drug coverage and criteria refer to the MassHealth Drug List.

We recommend submitting your prior authorization requests electronically via PromptPA.

Oncology Medical Management

If you are utilizing a medical drug for oncology purposes for a Harvard Pilgrim Health Care Commercial or Stride (HMO/ HMO-POS) Medicare Advantage member, prior authorization is necessary through OncoHealth. For more information, please refer to the OncoHealth link on the Medical Necessity Guidelines page and the Harvard Pilgrim vendor programs resource page.

Medical Drugs Available through Specialty Pharmacies

You can access a number of medical benefit drugs through specialty pharmacies. Options are detailed in the “Office-Administered Medical Drugs” policies found on this page. There are 3 versions of this policy, based on product: for Harvard Pilgrim Health Care commercial, Tufts Health Plan Commercial and Tufts Medicare Preferred, and Tufts Health Direct.