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Harvard Pilgrim Health CareCommercial · Prior Auth · Prior Authorization · Oncology, Ophthalmology, Neurology +1 moreMedium impact

Point32Health medical drug program updates

Act
by Feb 1, 2026
Effective date
Feb 1, 2026
Identified
Jun 20, 2026

Summary

Point32Health (Harvard Pilgrim and Tufts) is adding prior authorization requirements for two new specialty drugs and resuming coverage of Elevidys gene therapy with updated criteria. All changes are effective February 1, 2026.

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What to do

by Feb 1, 2026 · 3 steps
01Billing team must update prior authorization requirements for J4302 (Ryoncil) for pediatric graft-vs-host disease, J3403 (Encelto) for macular telangiectasia, and J1413 (Elevidys) for Duchenne muscular dystrophy.
02Update billing system to flag these codes for prior auth verification.
03Review Point32Health Medical Necessity Guidelines for specific criteria before submitting claims.

Codes mentioned

J4302J3403J1413

Original notice

Point32Health medical drug program updates
point32health.org · Always check the source before changing claims.
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Related changes

See all Harvard Pilgrim Health Care changes →
Point32Health medical drug program updatesMediumEffective Oct 1, 2025 · Provider NewsletterPoint32Health medical drug program updatesMediumEffective Nov 1, 2026 · Prior AuthorizationPoint32Health medical drug program updatesHighEffective Oct 1, 2026 · Prior AuthorizationPoint32Health medical drug program updatesMediumEffective Aug 1, 2026 · Prior AuthorizationBrowse every Harvard Pilgrim Health Care change in the policy list

Related policy hubs

Harvard Pilgrim Health Care policiesOncologyOphthalmologyNeurologyPediatricsCode J4302Code J3403Code J1413

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