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Harvard Pilgrim Health CareCommercial · Prior Auth · Provider Newsletter · Dermatology, Rheumatology, PharmacyHigh impact

Reauthorization requirements for targeted Immunomodulators

Act
by Dec 31, 2026
Effective date
Dec 31, 2026
Identified
Oct 14, 2026

Summary

Point32Health has implemented phased reauthorization requirements for targeted immunomodulator medications used for dermatological indications (hidradenitis suppurativa, plaque psoriasis, psoriatic arthritis) across Harvard Pilgrim Health Care Commercial and Tufts Health Direct. Existing prior authorizations were terminated on June 30, 2026 for members using these drugs for over one year; additional authorizations will terminate on December 31, 2026 for members reaching one year of use by January 1, 2027, requiring new prior authorization requests submitted beginning January 1, 2027 under updated reauthorization criteria.

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What to do

by Dec 31, 2026 · 6 steps
01Billing and authorization teams must identify patients on targeted immunomodulator medications for hidradenitis suppurativa, plaque psoriasis, or psoriatic arthritis who will have completed at least one year of utilization by January 1, 2027, as existing prior authorizations will terminate on this date.
02Beginning January 1, 2027: Providers must submit new prior authorization requests for continued treatment via PromptPA (preferred) or standard authorization processes.
03Authorization submissions must include all required clinical documentation including diagnosis, treatment response, and ongoing need for therapy.
04Requests will be reviewed under updated Reauthorization Criteria.
05Failure to obtain reauthorization will result in loss of continued access to therapy for affected patients.
06Front-office and authorization staff should verify plan applicability (Harvard Pilgrim Health Care Commercial and Tufts Health Direct only; Tufts Health Plan Commercial is discontinuing as of January 1, 2027) before implementing workflow changes.

Original notice

Reauthorization requirements for targeted Immunomodulators
point32health.org · Always check the source before changing claims.
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Related changes

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Reauthorization requirements for targeted immunomodulatorsHighEffective Jun 30, 2026 · Provider NewsletterBrowse every Harvard Pilgrim Health Care change in the policy list

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