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 (the parent company of Harvard Pilgrim Health Care and Tufts Health Plan) Medical Benefit Drug Medical Necessity Guidelines page.
Alternatively, some medical drugs are managed through an arrangement with OncoHealth when utilized for oncology purposes for Harvard Pilgrim 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 |
| Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J9999). |
11/1/2024 |
| Boruzu (bortezomib) | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J9999). |
11/1/2024 |
| New prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Alyglo
Unified Medical Policies |
Tufts Health Together
Prior authorization will be required for Aylglo (HPCS J1599), approved in December 2023 for the treatment of primary humoral immunodeficiency in adults. |
1/6/2025 |
| Unified Medical Policies
Beqvez
|
Tufts Health Together
Prior authorization will be required for Beqvez (HCPCS C9172), a gene therapy approved by the FDA in April 2024 for use in adults with moderate to severe hemophilia B who are receiving routine prophylaxis. |
11/12/2024 |
| Rytelo
(imetelstat)
|
Tufts Health RITogether, Tufts Health Plan Commercial, Tufts Health Direct
Prior authorization is now required for Rytelo (HCPCS C9399, J3490), approved by the FDA in April 2024 for the treatment of adult patients with low- to intermediate-1 risk myelodysplastic syndromes with transfusion-dependent anemia requiring 4 or more red blood cell units over 8 weeks who have not responded to or have lost response to or are ineligible for erythropoiesis-stimulating agents. |
11/1/2024 |
| Tremfya (guselkumab) intravenous
Targeted Immunomodulators – Skilled Administration (Commercial and Direct) Targeted Immunomodulators – Skilled Administration (RITogether) |
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Prior authorization is now required for Tremfya IV (HCPCS J1628), approved by the FDA in September 2024 for the treatment of adult patients with moderately to severely active ulcerative colitis. |
11/1/2024 |
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Lanreotide (cipla)
Somatostatin Analogs for Non-Oncology Indications (Commercial and Direct) Somatostatin Analogs for Oncology Indications (Commercial and Direct) Somatostatin Analogs (Tufts Health RITogether) |
Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct
Lanreotide (cipla) (HCPCS J1932) will be added to the Medical Necessity Guideline.
|
1/1/2025 |
| Xiaflex (collagenase clostridium histolyticum) | Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether | 1/1/2025 |
| Elrexfio, Talvey
Unified Medical Policies |
Tufts Health Together
Elrexfio and Talvey will remain managed with prior authorization; however, effective for fill dates on or after Dec. 1, 2024, coverage criteria will be unified with MassHealth. As a result, Elrexfio and Talvey will now fall under the Unified Medical Policies MNG. |
12/1/2024 |
Unified Medical Policies
|
Tufts Health Together
Updates to criteria to align with MassHealth guidance and FDA labels. Refer to the Unified Medical Policies MNG and MassHealth Drug List criteria for more details. |
11/12/2024 |
| Tremfya IV
Targeted Immunomodulators – Skilled Administration (Commercial and Direct)
|
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 11/1/2024 |
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