CommercialCoverageMedium impact
Change in process for new-to-market pharmacy benefit drugs
Harvard Pilgrim Health Care·Pharmacy
Effective date
Jun 1, 2026
We identified it
Jun 20, 2026
Summary
Point32Health (Harvard Pilgrim Health Care and Tufts Health Plan) will deny all new-to-market pharmacy benefit drug requests as of June 1, 2026, until their committee reviews each drug for safety and effectiveness. Exceptions will only be granted on second request for life-threatening conditions meeting specific medical necessity criteria.
Action Required
Before June 1, 2026: Billing team must update prior authorization processes for Point32Health plans to expect automatic denials for all new-to-market pharmacy drugs. Train staff that exceptions require second requests and documentation of life-threatening conditions per updated Pharmacy Medical Necessity Guidelines for Non-Formulary Exceptions. Update patient counseling materials to warn about coverage delays for new drugs.