| Updates to existing prior authorization programs | |||
| Drug | Plan | Eff. date | Policy & additional information |
| Repatha, Praluent, Nexletol, Nexlizet | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | March 1, 2025 | Lipid Lowering Agents |
| Quantity Limit Exceptions | Harvard Pilgrim Health Care commercial, Tufts Health Plan commercial, Tufts Health Direct | March 1, 2025 | Quantity Limit Exceptions |
Bowel preparations used for colorectal cancer screening
Applicable to Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct
In alignment with recommendations from the United States Preventive Services Task Force (USPSTF), Point32Health covers the full cost of generic bowel preparation agents for members ages 45 to 75. Generic bowel prep agents have the same clinical efficacy as branded formulations and offer a lower-cost alternative. To support the use of lower-cost alternatives and to protect members from cost-sharing, we encourage health care providers to prescribe generic bowel preparation agents for colorectal cancer screening.
When a branded formulation is medically necessary, a coverage exception request must be submitted. To request an exception, the prescribing provider must request coverage through the medical review process, subject to our Non-Formulary Exceptions Pharmacy Medical Necessity Guidelines.
The following bowel preparation medications are moving to non-formulary, effective for dates of service beginning April 1, 2025:
- Clenpiq
- Osmoprep