CommercialCoverageHigh impact
OTC drug exclusions and other formulary updates
Harvard Pilgrim Health Care·Pharmacy
Effective date
Oct 1, 2026
We identified it
Jul 14, 2026
Summary
Effective October 1, 2026, Point32Health will exclude coverage for over-the-counter (OTC) drugs and prescription medications with OTC equivalents for Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, and Tufts Health Direct members. Affected drug categories include 2nd generation antihistamines, H2 blockers, nasal steroids, prescription fluoride, and proton pump inhibitors. Exceptions apply for pediatric formulations, drugs without OTC equivalents, and ACA-mandated products.
Action Required
By September 1, 2026: Billing team must review and update pharmacy claim submission processes and billing system rules to reflect new OTC exclusions for affected Point32Health plans (Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct). Identify all claims currently billing OTC-equivalent medications (antihistamines, H2 blockers, nasal steroids, fluoride, PPIs) and establish denial protocols. Coordinate with providers and clinical staff to: (1) document medical necessity when pediatric formulations or ACA-mandated exceptions apply, (2) update prescription templates to reflect coverage changes, (3) prepare patient communication materials explaining new cost-sharing responsibilities. Update billing system logic to automatically deny or route for manual review claims for excluded OTC drugs unless exception criteria are met. Failure to implement these changes will result in claim denials and member complaints beginning October 1, 2026. Refer to the detailed formulary updates document at https://www.point32health.org/provider/otc-drug-exclusions-and-other-formulary-updates-072026 for the complete list of affected medications.