CommercialPrior AuthHigh impact
Point32Health medical drug program updates
Harvard Pilgrim Health Care·Oncology, Hematology, Neurology +2 more·Provider Newsletter
Effective date
Aug 1, 2025
We identified it
Jun 26, 2026
Summary
Point32Health has implemented new prior authorization requirements for multiple oncology and specialty drugs across Harvard Pilgrim and Tufts Health plans, effective August 1, 2025 through November 1, 2025. Additionally, CAR-T cell therapies have been updated to remove REMS-only restrictions and clarify immunosuppressive therapy limitations, with new pediatric indications added for certain drugs. A new Parkinson's disease drug (Onapgo) now requires prior authorization effective September 1, 2025.
Action Required
By August 1, 2025: Billing team must implement prior authorization requirements in all billing systems for penpulimab-kcqx (J9999). By September 1, 2025: Billing team must update systems to require prior authorization for Dr. Reddy's bendamustine (J9999), Denosumab-BHNT/Bomyntra (J3590), Lynozyfic (J9999), Avgemsi (J9999), and Onapgo (J3490). Update encounter templates and billing workflows to trigger prior auth requests before claim submission. For CAR-T therapies (Abecma, Aucatzyl, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta) effective September 1, 2025: Remove all language restricting these drugs to REMS programs only, and update prior authorization criteria to clarify that immunosuppressive therapy limitations apply only if therapy is likely to interfere with T cell function. Add new pediatric indications for Breyanzi and Yescarta. By November 1, 2025: Implement prior authorization requirements for Actemra (J3262), Tofidence (Q5133), and Tyenne (Q5135) for Harvard Pilgrim commercial members. Reference Point32Health Medical Necessity Guidelines and OncoHealth portal for coverage criteria. Failure to obtain prior authorization will result in claim denials.