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Point32Health medical drug program updates
Act
by Aug 1, 2025
Effective date
Aug 1, 2025
Identified
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.
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What to do
by Aug 1, 2025 · 7 steps
01Billing team must implement prior authorization requirements in all billing systems for penpulimab-kcqx (J9999).
02By 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).
03Update encounter templates and billing workflows to trigger prior auth requests before claim submission.
04For 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.
05Add new pediatric indications for Breyanzi and Yescarta.
06By November 1, 2025: Implement prior authorization requirements for Actemra (J3262), Tofidence (Q5133), and Tyenne (Q5135) for Harvard Pilgrim commercial members.
07Reference Point32Health Medical Necessity Guidelines and OncoHealth portal for coverage criteria.
If missed: Failure to obtain prior authorization will result in claim denials.
Codes mentioned
J3262Q5133Q5135J9999J3590J3490
Original notice
Point32Health medical drug program updates
point32health.org · Always check the source before changing claims.
Related changes
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