| Updates to existing prior authorization programs | |||
| Drug | Plan | Eff. date | Policy & additional information |
| Contrave (naltrexone/bupropion) extended-release tablet
Saxenda (liraglutide) Injection Wegovy (semaglutide) injection Zepbound (tirzepatide) injection
|
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 7/1/2025 | Weight Loss Medications
Removed Wegovy and Saxenda from the MNG. Added age of 18 years or older to initial criteria for Zepbound and Contrave. Added requirement in reauthorization criteria for submission of baseline and follow-up weights from visit. Added limitation statement that the plan will not authorize coverage of a GLP-1 agonist or GLP-1 compounded product that is not FDA-approved for weight loss. For more details, please refer to this article also published in this issue of Insights and Updates for Providers. |
| Non-Formulary Exceptions | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 7/1/2025 | Non-Formulary Exceptions
Added clarification about documentation of needle phobia when requesting injectable products. Added clarification on adequate trial of preferred weight loss medications for applicable formularies. Added clarification for formulary alternatives as appropriate for member’s age. |
| Serostim (somatropin) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 6/1/2025 | Lipodystrophy Agents: Egrifta SV (tesamorelin) and Serostim (somatropin)
Removed Serostim from coverage criteria for Human Immunodeficiency Virus (HIV)-associated Lipodystrophy. |
| Aimovig (erenumab-aooe)
Ajovy (fremanezumab-vfrm) Emgality (galcanezumab-gnlm) – Ubrelvy (ubrogepant) – Nurtec ODT (rimegepant) Qulipta (atogepant) |
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 6/1/2025 | Non-Triptan Migraine Medications
Added a limitation that gabapentin and pregabalin are not considered valid trial of anticonvulsant medications for migraine prophylaxis. |
| Voquezna (vonoprazan | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 6/1/2025 | Voquezna Pak
Removed clarithromycin-based therapy as a prerequisite for members who have a contraindication or intolerance to bismuth quadruple therapy. |
| Drug Status Changes | |||
| Drug | Plan | Eff. Date | Policy & additional information |
| Vigabatrin 500 mg tablet | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together | 6/1/2025 | Vigabatrin 500 mg tablet will be added to the specialty pharmacy program provided by Optum Specialty. |
| Saxenda (liraglutide) Injection | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 7/1/2025 | Weight Loss Medications
Saxenda (liraglutide) injection will be moved to non-formulary. For more details, please refer to this article also published in this issue of Insights and Updates for Providers. |
| Wegovy (semaglutide) injection | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 7/1/2025 | Weight Loss Medications
Wegovy (semaglutide) injection will be moved to non-formulary. For more details, please refer to this article also published in this issue of Insights and Updates for Providers. |
| Sumatriptan-Naproxen tablet | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 7/1/2025 | Sumatriptan-Naproxen tablet will be moved to non-formulary. |
| Almotriptan malate tablet | Harvard Pilgrim Commercial, Tufts Health Plan Commercial | 7/1/2025 | Almotriptan malate tablets are moving to a higher tier on the Premium, Value, and Core ME/Core NH/Core RI formularies, as outlined in the table below. |
| Drug Name | Formulary | ||||||
| Premium | Value | Core ME/Core NH/Core RI | |||||
| 4-Tier | 3-Tier | 5-Tier | 4-Tier | 3-Tier | 5-Tier | 4-Tier | |
| almotriptan malate tablet | Tier 3 | Tier 2 | Tier 3 | Tier 2 | Tier 2 | Tier 3 | Tier 2 |