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Point32Health medical drug program updates
Act
by Oct 1, 2025
Effective date
Oct 1, 2025
Identified
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.
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What to do
by Oct 1, 2025 · 4 steps
01Update billing system to require prior authorization for new drugs: Avtozma (Q5156), Tocilizumab Fresenius and Tocilizumab Celltrion (both J9999), Encelto (J3403), Ryoncil (J3402), and Kebilidi.
02For Harvard Pilgrim oncology cases, submit prior auth requests through OncoHealth.
03For Tufts plans, follow MassHealth criteria.
04Update encounter forms to alert providers of new prior auth requirements.
Codes mentioned
Q5156J9999J3403J3402
Original notice
Point32Health medical drug program updates
point32health.org · Always check the source before changing claims.
Related changes
See all Harvard Pilgrim Health Care changes →Point32Health medical drug program updatesHighEffective Aug 1, 2025 · Provider NewsletterPoint32Health medical drug program updatesHighEffective Dec 1, 2025 · Prior AuthorizationPoint32Health medical drug program updatesMediumEffective Feb 1, 2026 · Prior AuthorizationPoint32Health medical drug program updatesHighEffective Apr 1, 2026 · Prior AuthorizationBrowse every Harvard Pilgrim Health Care change in the policy list