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Point32Health medical drug program updates
Effective date
Nov 1, 2026
Identified
Nov 4, 2026
Summary
Point32Health (Harvard Pilgrim and Tufts Health plans) is adding or changing prior authorization (PA) for several medical benefit drugs in stages, with dates from November 1, 2026 through January 1, 2027. The notice adds PA for Zevaskyn (J3389), requires PA for Otarmeni (J3590) under the MassHealth carve-out list, requires PA for Omisigre (J3406) on Medicare plans, and adds step-therapy and diagnosis criteria for complement inhibitors, Imaavy, Uplizna, denosumab and others. The November 1, 2026 date has passed as of the analysis date, so confirm it is in effect for each plan; the November 16, 2026 and January 1, 2027 items are still upcoming.
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What to do
Action · 13 steps
01Dates are staged, so handle each one separately.
02The source issue date is November 5, 2026, one day after the analysis date, so confirm current status with the payer before acting.
03Previously due November 1, 2026 (date passed; verify current applicability) (stated in the source; now passed, so confirm it is in effect): Billing team and providers, for Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct and Tufts Health RITogether, get PA before scheduling Zevaskyn (J3389) for recessive epidermolysis bullosa, and check the Medical Necessity Guidelines on the Point32Health medical drug page.
04For Casgevy, the age limit was expanded to ages 2 and older who weigh at least 12 kg for sickle cell disease and beta thalassemia on the listed plans; update the PA tracker and eligibility checks.
05For Tufts Medicare Preferred, Tufts Health Plan SCO and Tufts Health One Care: Breyanzi adds marginal zone lymphoma as an approved indication with the criteria listed in the source; Omisigre (J3406) requires PA, and its criteria now include severe aplastic anemia and treatment at centers with stem cell transplant expertise.
06By November 16, 2026: Tufts Health Together MassHealth carve-out members: Otarmeni (J3590) requires PA for severe-to-profound hearing loss linked to otoferlin gene variants, and providers should bill J3590.
07Update the charge entry and PA tracker before scheduling.
08By January 1, 2027: Billing team and providers, update PA tracking and the step-therapy workflow for these plans.
09For Harvard Pilgrim Commercial and Tufts Health Direct: a step through Rystiggo or Vyvgart/Vyvgart Hytrulo is required for generalized myasthenia gravis for Imaavy and Uplizna; Cinryze gets added diagnostic criteria for hereditary angioedema; and new-to-market exception criteria are updated.
10For Tufts Health RITogether: a step through Epysqli is required for Bkemv, Soliris and Ultomiris on shared indications, and a step through Avtozma is required for Actemra, Tofidence and Tyenne.
11For Tufts Medicare Preferred, Tufts Health Plan SCO and Tufts Health One Care: a second step is added for non-preferred denosumab products, and Stoboclo, Osenvelt, Bildyos, Biprevda, Enoby and Xtrenbo are step-2 or preferred products.
12Rare disease categories added for aHUS, NMOSD, Biopsy Proven Dense Deposit Disease, PNH and gMG list preferred products in the source.
13The source does not state what happens to claims without these steps, so do not assume a consequence.
Codes mentioned
J3389J3590J3406
Original notice
Point32Health medical drug program updates
point32health.org · Always check the source before changing claims.
Related changes
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