CommercialPrior AuthMedium impact
Point32Health medical drug program updates
Harvard Pilgrim Health Care·Oncology, Ophthalmology, Genetics +1 more·Provider Newsletter
Effective date
Oct 1, 2025
We identified it
Jun 20, 2026
Summary
Point32Health (Harvard Pilgrim and Tufts Health Plan) added prior authorization requirements for multiple new drugs including tocilizumab biosimilars for oncology use and gene therapy drugs. The policy also relaxed some existing prior authorization criteria by removing treatment center requirements for T-cell immunotherapies and certain monitoring requirements for Luxturna.
Action Required
By October 1, 2025: Update billing system to require prior authorization for new drugs: Avtozma (Q5156), Tocilizumab Fresenius and Tocilizumab Celltrion (both J9999), Encelto (J3403), Ryoncil (J3402), and Kebilidi. For Harvard Pilgrim oncology cases, submit prior auth requests through OncoHealth. For Tufts plans, follow MassHealth criteria. Update encounter forms to alert providers of new prior auth requirements.