CommercialCoverageHigh impact
Reminder: OTC drug exclusions and other formulary updates
Harvard Pilgrim Health Care·Pharmacy·Pharmacy
Effective date
Oct 1, 2026
We identified it
Aug 2, 2026
Summary
Effective October 1, 2026, Point32Health (Harvard Pilgrim, Tufts Health Plan Commercial, and Tufts Health Direct) will exclude coverage for over-the-counter drugs and prescription medications with OTC equivalents, including 2nd generation antihistamines, H2 blockers, nasal steroids, prescription fluoride, and proton pump inhibitors. Exceptions apply for pediatric formulations, products without OTC equivalents, and ACA-mandated drugs.
Action Required
By September 1, 2026: Billing and clinical teams must (1) Review the detailed Oct. 1, 2026 drug status and formulary updates document at https://www.point32health.org/provider/reminder-otc-drug-exclusions-and-other-formulary-updates-082026 to identify which specific drug products are moving to non-formulary or excluded status; (2) Update billing system rules and edits to flag or reject claims for excluded OTC drugs and prescription drugs with OTC equivalents for Harvard Pilgrim, Tufts Health Plan Commercial, and Tufts Health Direct members; (3) Educate providers and clinical staff on the exclusions to prevent inappropriate prescribing; (4) Update patient education materials and prior authorization templates to reflect coverage denials for these drug categories; (5) Configure system alerts to notify billing staff when claims contain excluded drugs so corrective action can be taken before submission. Failure to implement these changes will result in claim denials and revenue loss for excluded medications.