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 | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
|
Rytelo (imetelstat)
|
Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Prior authorization will be 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. |
1/1/2025 |
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Botulinum Toxins
|
Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Botox (onabotulinumtoxin A), Daxxify (daxibotulinumtoxinA-lanm), Dysport (abobotulinumtoxin A), Myobloc (rimabotulinumtoxin B) and Xeomin (incobotulinumtoxinA) individual medical necessity guidelines have been consolidated into a therapeutic class Botulinum Toxins medical necessity guideline. Coverage in line with CMS LCDs and FDA approved indications is now applied consistently across all botulinum toxin products. Botox and Xeomin remain the preferred Botulinum Toxin products. |
2/1/2025 |
| Leqvio (inclisiran) | Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | 2/1/2025 |
| Spravato (esketamine) | Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | 2/1/2025 |