CommercialPrior AuthMedium impact
Point32Health medical drug program updates
Harvard Pilgrim Health Care·Oncology, Ophthalmology, Neurology +1 more·Prior Authorization
Effective date
Feb 1, 2026
We identified it
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.
Action Required
By February 1, 2026: Billing 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. Update billing system to flag these codes for prior auth verification. Review Point32Health Medical Necessity Guidelines for specific criteria before submitting claims.