| New prior authorization programs | |||
| MNG title | Products affected | Effective date | Summary |
| Elrexfio (elranatamab-bcmm) (Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Together) | Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Together, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Unify | Dec. 1, 2023 | Prior authorization is now required for Elrexfio (HCPCS J9999), approved August 2023, for the treatment of adult patients with relapsed or refractory multiple myeloma who have received at least four prior lines of therapy including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody |
| Talvey (talquetamab-tgvs) (Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Together) | Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Together, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Unify | Dec. 1, 2023 | Prior authorization is now required for Talvey (HCPCS J9999), approved August 2023, for the treatment of adult patients with relapsed or refractory multiple myeloma who have received at least four prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent and an anti-CD38 monoclonal antibody |
| Asparaginase Products (Tufts Health Plan commercial, Tufts Health Direct) | Tufts Health Plan commercial, Tufts Health Direct | Feb. 1, 2024 | Prior authorization will be required for Erwinase (HCPCS J9019) and Rylaze (HCPCS J9021) approved as a component of a multi-agent chemotherapeutic regimen for the treatment of acute lymphoblastic leukemia and lymphoblastic lymphoma patients who have developed hypersensitivity to E. coli-derived asparaginase, respectively. |
| Roctavian | Tufts Health Together | December 4, 2023 | Prior authorization will now be required for Roctavian (HCPCS J3590). See Unified Medical Policies for details. |
| Updates to existing prior authorization programs | |||
| Drug(s) | Products affected | Effective date | Policy & additional Information |
| Cerezyme, Elelyso, Evkeeza, Kanuma, Nulibry, Scenesse, Tepezza, Vimizim, VPRIV | Tufts Health Together | Feb. 1, 2024 | Unified Medical Policies |
| Immune globulins | Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether | Feb. 1, 2024 | Intravenous Immune Globulin (IVIG) and Subcutaneous Immune Globulin (SCIG) Products (Harvard Pilgrim, Tufts Health Plan) |
| Aralast NP, Glassia, Prolastin-C | Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether | Feb. 1, 2024 | Alpha1-Proteinase Inhibitors (Harvard Pilgrim, Tufts Health Plan) |
| Epoprostenol, Flolan, Remodulin | Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether | Feb. 1, 2024 | Pulmonary Hypertension Medications: Epoprostenol products, Remodulin (Harvard Pilgrim, Tufts Health Plan) |
| Saphnelo | Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether | Feb. 1, 2024 | Saphnelo (Harvard Pilgrim, Tufts Health Plan) |
| Xenopozyme | Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether | Feb. 1, 2024 | Xenopozyme (Harvard Pilgrim, Tufts Health Plan) |
| Xiaflex | Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether | Feb. 1, 2024 | Xiaflex (Harvard Pilgrim, Tufts Health Plan) |
| Amondys 45, Exondys 51, Viltepso, Vyondys 53 | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Senior Care Options, Tufts Health Unify | Feb. 1, 2024 | Amondys 45 (Harvard Pilgrim, Tufts Health Plan)
Exondys 51 (Harvard Pilgrim, Tufts Health Plan) Viltepso (Harvard Pilgrim, Tufts Health Plan) Vyondys 53 (Harvard Pilgrim, Tufts Health Plan) |
| Cinryze | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Senior Care Options, Tufts Health Unify | Feb. 1, 2024 | Cinryze (Harvard Pilgrim, Tufts Health Plan) |
| Haegarda | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare, Tufts Medicare Preferred, Senior Care Options, Tufts Health Unify | Feb. 1, 2024 | Haegarda (Harvard Pilgrim, Tufts Health Plan) |
| Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare, Tufts Medicare Preferred, Senior Care Options, Tufts Health Unify | Feb. 1, 2024 | Rituximab Products Non-Oncology Indications (Harvard Pilgrim, Tufts Health Plan)
Rituximab Products Oncology Indications (Tufts Health Plan)
|
| Saphnelo | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare, Tufts Medicare Preferred, Senior Care Options, Tufts Health Unify | Feb. 1, 2024 | Saphnelo (Harvard Pilgrim, Tufts Health Plan) |
| Scenesse | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare, Tufts Medicare Preferred, Senior Care Options, Tufts Health Unify | Feb. 1, 2024 | Scenesse (Harvard Pilgrim, Tufts Health Plan) |
| Takhzyro | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare, Tufts Medicare Preferred, Senior Care Options, Tufts Health Unify | Feb. 1, 2024 | Takhzyro (Harvard Pilgrim, Tufts Health Plan) |
| Uplinza | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare, Tufts Medicare Preferred, Senior Care Options, Tufts Health Unify | Feb. 1, 2024 | Uplinza (Harvard Pilgrim, Tufts Health Plan) |
| Xenpozyme | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Senior Care Options, Tufts Health Unify | Feb. 1, 2024 | Xenpozyme (Harvard Pilgrim, Tufts Health Plan) |
| Actemra IV, Avsola, Entyvio IV, Ilumya, Inflectra, Infliximab, Orencia IV, Remicade, Renflexis Simponi Aria, Skyrizi IV, Stelara IV | Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health RITogether, Tcufts Health Direct | Feb. 1, 2024 | Targeted Immunomodulators Skilled Administration (Harvard Pilgrim, Tufts Health Plan Commercial, Tufts Health Direct)
Targeted Immunomodulators Skilled Administration (Tufts Heath RITogether) |
| Skysona, Adstiladrin | Tufts Health Together | December 4, 2023 | Internal Medical Benefit Drug Policies for Skysona (HCPCS J3590) and Adstiladrin (HCPCS J9999) will be retired. Skysona and Adstiladrin will continue to require prior authorization, see Unified Medical Policies for details. |
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