| New prior authorization programs | |||
| MNG title | Products affected | Effective date | Summary |
| Izervay (Harvard Pilgrim commercial)
Izervay (Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage) Izervay (Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Together, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | Jan. 1, 2024 | Prior authorization is now required for Izervay (HCPCS C9162), approved August 2023, for the treatment of geographic atrophy secondary to age-related macular degeneration. |
| Daxxify (Harvard Pilgrim commercial)
Daxxify (Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether) Daxxify (Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage) Daxxify (Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | Jan. 1, 2024 | Prior authorization is now required for Daxxify (HCPCS C9160), approved August 2023, for the treatment of cervical dystonia in adult patients. |
| Part B Step Therapy Policy (Harvard Pilgrim) | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | Jan. 1, 2024 | Step Therapy is now required for Eylea HD (HCPCS C9161), approved August 2023, for the treatment of neovascular (wet) age-related macular degeneration, diabetic macular edema, and diabetic retinopathy. |
| Roctavian (Harvard Pilgrim commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage)
Roctavian (Tufts Health Plan Senior Care Options, Tufts Health One Care) |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred Tufts Health Plan Senior Care Options, Tufts Health One Care | Jan. 1, 2024 | Prior authorization is now required for Roctavian (HCPCS J1412), approved June 2023 for the treatment of adults with severe Hemophilia A. |
| Vyjuvek (Harvard Pilgrim commercial)
Vyjuvek (Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether) Vyjuvek (Tufts Health Together) Vyjuvek (Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage) Vyjuvek (Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care) |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Together, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred Tufts Health Plan Senior Care Options, Tufts Health One Care | Jan. 1, 2024 | Prior authorization is now required for Vyjuvek (HCPCS J3401), approved May 2023 for members 6 months of age and older with dystrophic epidermolysis bullosa with pathogenic variant(s) in the collagen type VII alpha 1 chain (COL7A1) gene. |
| Elevidys (Harvard Pilgrim commercial) | Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Together | Jan. 1, 2024 | Prior authorization is now required for Elevidys (HCPCS J1413), approved June 2023 for the treatment of ambulatory pediatric patients aged 4 through 5 years with Duchenne muscular dystrophy (DMD) with a confirmed pathogenic variant in the DMD gene. |
| Omisirge (See Unified Policies MNG for more details.) | Tufts Health Together | Jan 2, 2024 | Prior authorization is now required for Omisirge (HCPCS J3590), approved April 2023 for use in adults and pediatric patients 12 years and older with hematologic malignancies who are planned for umbilical cord blood transplantation following myeloablative conditioning to reduce the time to neutrophil recovery and the incidence of infection. |
| Pluvicto | Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether | March 1, 2024 | Prior authorization is now required for Pluvicto (HCPCS A9607), approved March 2022 for for the treatment of adult patients with prostate-specific membrane antigen (PSMA) – positive metastatic castration-resistant prostate cancer (mCRPC) who have been treated with androgen receptor (AR) pathway inhibition and taxane-based chemotherapy. |
| Rykindo | Tufts Health Together | March 1, 2024 | Prior authorization is now required for Rykindo (HCPCS J3490) approved January 2023, for the treatment of schizophrenia and bipolar I disorder. |
| Updates to existing prior authorization programs | |||
| Drug(s) | Products affected | Effective date | Policy & additional Information |
| Hemgenix | Tufts Health Together | Jan 2, 2024 | Hemgenix will continue to require prior authorization but will now use MassHealth coverage criteria. See Unified Policies MNG for more details. |
| Crysvita | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | March 1, 2024 | Crysvita (Harvard Pilgrim, Tufts Health Plan) |
| Cinqair, Fasenra, Nucala | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | March 1, 2024 | Respiratory Interleukin Skilled Administration (Harvard Pilgrim, Tufts Health Plan) |
| Epoprostenol products, Remodulin, Tyvaso, Ventavis | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care | March 1, 2024 | Pulmonary Hypertension Medications (Harvard Pilgrim, Tufts Health Plan) |
| Aranesp, Epogen, Mircera, Procrit, Retacrit | Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct | March 1, 2024 | Erythropoiesis Stimulating Agents (Harvard Pilgrim, Tufts Health Plan) |
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