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 |
| Bizengri | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J9999). |
2/1/2025 |
| Unloxcyt | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J9999). |
2/1/2025 |
| Opdivo Qvantig | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J9999). |
2/1/2025 |
| Vyloy | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J9999). |
2/1/2025 |
| Ziihera | Harvard Pilgrim Commercial
Prior authorization is now required (HCPCS code J9999). |
2/1/2025 |
| Elevidys | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether
Clarification that the length of authorization is 90 days from the date of approval or up to the member’s 6th birthday, whichever comes first. |
2/1/2025 |
| Updates to existing prior authorization programs for OncoHealth drugs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Docivyx | Harvard Pilgrim Commercial
Prior authorization is no longer required (HCPCS code J9172). |
2/1/2025 |
| Docetaxal | Harvard Pilgrim Commercial
Prior authorization is no longer required (HCPCS code J9172). |
2/1/2025 |
| New prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Vafseo (vadadustat)
Unified Medical Policies |
Tufts Health Together
Prior authorization will be required for Vafseo (HCPCS J0901), approved by the FDA in March 2024 for the treatment of anemia due to chronic kidney disease in adults who have been receiving dialysis for at least three months. Coverage criteria will be unified with MassHealth. |
4/1/2025 |
| Jesduvroq (daprodustat)
Unified Medical Policies |
Tufts Health Together
Prior authorization will be required for Jesduvroq (HCPCS J0889), approved by the FDA in February 2023 for the treatment of anemia due to chronic kidney disease in adults who have been receiving dialysis for at least fourth months. Coverage criteria will be unified with MassHealth. |
4/1/2025 |
| PiaSky (crovalimab-akkz)
Unified Medical Policies |
Tufts Health Together
Prior authorization will be required for PiaSky (HCPCS J1307), approved by the FDA in June 2024 for the treatment of adult and pediatric patients 13 years and older with paroxysmal nocturnal hemoglobinuria and body weight of at least 40 kg. Coverage criteria will be unified with MassHealth. |
2/18/2025 |
| Tecelra
Unified Medical Policies |
Tufts Health Together
Prior authorization will be required for coverage of Tecelra (J9999) a gene therapy approved by the FDA in August 2024 to treat adults with metastatic synovial sarcoma. Coverage criteria will be unified with MassHealth. |
2/18/2025 |
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Kisunla (donanemab-azbt) | Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 4/1/2025 |
| Leqembi (lecanemab) | Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 4/1/2025 |
| Epkinly (epcoritamab-bysp), Opdualag (nivolumab/relatlimab-rmbw), Tecvayli (teclistamab-cqyv)
Unified Medical Policies |
Tufts Health Together
Epkinly, Opdualag, and Tecvayli will remain managed with prior authorization; however, effective for fill dates on or after Feb. 18, 2025, coverage criteria will be unified with MassHealth. As a result, Epkinly, Opdualag, and Tecvayli will now fall under the Unified Medical Policies Medical Necessity Guidelines. |
2/18/2025 |