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 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 commercial and Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage members. You can find prior authorization policies for these drugs via the OncoHealth page in the Vendor Programs section of the Harvard Pilgrim provider website, or directly on OncoHealth’s webpage for Harvard Pilgrim.
| New prior authorization programs for OncoHealth drugs | ||||
| Drug(s) | Plan | Eff. date | Policy & Additional Information | |
| Talvey | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Harvard Pilgrim commercial | Apr. 1, 2024 | Talquetamab-tqvs (Talvey) | |
| Elrexfio | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Harvard Pilgrim commercial | Apr. 1, 2024 | Elranatamab-bcmm (Elrexfio) | |
| Loqtorzi | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Harvard Pilgrim commercial | Apr. 1, 2024 | PD-1/PD-L1s | |
| Updates to existing prior authorization programs | ||||
| Drug(s) | Plan | Eff. date | Policy & Additional Information | |
| Tecvayli | Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Harvard Pilgrim commercial | Apr. 1, 2024 | Coverage criteria will transition from the Point32Health Medical Necessity Guidelines to OncoHealth Chemotherapy Review Criteria.
The policy will be available on the OncoHealth webpage for Harvard Pilgrim prior authorization criteria in alignment with the April 1 effective date. |
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| Bavencio, Imfinzi, Jemperli, Keytruda, Libtayo, Opdivo, Opdualag, Tecentriq, Zynyz
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Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Harvard Pilgrim commercial | Apr. 1, 2024 | PD-1/PD-L1s
Medications in this drug class will be grouped together under the new policy tilted PD-1/PD-L1s. In accordance with the policy, authorizations are for six months, after which time they must be reviewed for efficacy, safety, and tolerability. Maximum total length of therapy with checkpoint inhibitors for metastatic non-small cell lung cancer is 2 years. The policy will be available on the OncoHealth webpage for Harvard Pilgrim prior authorization criteria in alignment with the April 1 effective date. |
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