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 Commercial and Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage members. You can find information about this program on the OncoHealth page in the Vendor Programs section of the Harvard Pilgrim 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.
| Visit our new Medical Drug Medical Necessity Guidelines page to access these policies (unless otherwise noted). |
| Medications being added to prior authorization | ||
| MNG/Drug(s) | Plan & additional information | Eff. date
|
| Zymfentra (infliximab-dyyb)
Targeted Immunomodulators – Skilled Administration Part B Step Therapy |
Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Prior authorization is now required for Zymfentra (HCPCS J1748), approved by the FDA in Oct. 2023 for the maintenance treatment of adults with moderately to severely active ulcerative colitis following treatment with an infliximab product administered intravenously, and moderately to severely active Crohn’s disease following treatment with an infliximab product administered intravenously. |
7/1/2024 |
| Ryzneuta (efbemalenograstim alfa)
Part B Step Therapy OncoHealth Part B Step Therapy Long-acting Colony Stimulating Factor Products |
Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Prior authorization is now required for Ryzneuta (J9361), approved by the FDA in Nov. 2023 to decrease the incidence of infection, as manifested by febrile neutropenia, in adults with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia. |
7/1/2024 |
| Amtagvi (lifileucel) | Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options
Amtagvi, a tumor derived autologous T cell immunotherapy approved by the FDA in March 2024 for the treatment of adult patient with unresectable or metastatic melanoma, is covered with prior authorization. Please note that for Tufts Health Together, requests for Amtagvi will be reviewed using the Point32Health Amtagvi (lifileucel) MNG found on our Medical Benefit Drug Medical Necessity Guidelines page until Aug. 12, 2024. Beginning Aug. 12, Amtagvi requests will be reviewed against the criteria on the MassHealth Drug List. |
7/1/2024 |
| Updates to existing prior authorization programs | ||
| MNG/Drug(s) | Plan & additional information | Eff. date |
| Zulresso (brexanolone) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether | 9/1/2024 |
| Adstiladrin (nadofaragene firadenovec-vncg)
Hemgenix (etranacogene dezaparvovec-drlb) Lyfgenia (lovotibeglogene autotemcel) Roctavian (valoctocogene roxaparvovec-rvox) Zynteglo (betibeglogene autotemcel)
|
Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options
Point32Health will now use MassHealth criteria for prior authorization review for these gene therapies. |
7/1/2024 |
| Elevydis
|
Tufts Health Together
Minor updates to MassHealth’s criteria. |
7/1/2024 |
| Lyfgenia
|
Tufts Health Together
For Tufts Health Together members, prior authorization review for Lyfgenia will now be managed using MassHealth criteria. |
7/1/2024 |
| Casgevy (exagamglogene autotemcel) | Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health One Care
Casgevy will now be covered with prior authorization for an additional indication: treatment resistant beta-thalassemia |
7/1/2024 |
|
Carvykti (ciltacabtagene autoleucel)
|
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Direct, Tufts Health RITogether
Carvykti has moved from a fourth-line treatment to a second-line treatment. |
7/1/2024 |
| Abecma (idecabtagene vicleucel)
|
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Direct, Tufts Health RITogether
Abecma has moved from a fourth-line treatment to a third-line treatment |
7/1/2024 |
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