Pharmacy Program Updates

As a reminder, Point32Health, the parent company of Harvard Pilgrim Health Care and Tufts Health Plan, is launching several enhancements to our pharmacy program, effective Jan. 1, 2023. This includes selecting OptumRx as our pharmacy benefit manager (PBM) for all products and streamlining utilization management for pharmacy and medical benefit drugs. Point32Health’s Pharmacy Utilization Management team will manage the intake and review of pharmacy and medical drug prior authorization requests.

2023 formularies and pharmacy guidelines now available
Our 2023 prescription drug formularies as well as our pharmacy medical necessity guidelines and our medical benefit drug necessity guidelines, are now available on our provider website.

We are retiring our 2022 formularies and introducing new pharmacy formularies for 2023.

In addition, for greater simplicity and an improved member and provider experience, we’ve unified our pharmacy medical necessity guidelines within product lines and our Commercial formularies. For example, our 2023 Commercial formularies apply for both Harvard Pilgrim and Tufts Health Plan Commercial members, and the same pharmacy medical necessity guidelines will apply for Harvard Pilgrim and Tufts Health Plan Commercial members alike. Guidelines may vary across product lines, however (for example, Commercial and Public Plans policies may differ). Refer to the Pharmacy and Medical Drug sections of our What’s Ahead at Point32Health: Integration Updates page, as well as the medical necessity criteria, for more information.

Online prior authorization submissions
In addition to having a single point of contact for pharmacy and medical drug benefit prior authorization requests, we’re making things even easier. Beginning Jan. 1, you will have access to PromptPA, a new online prior authorization submission tool for pharmacy and medical drugs. With PromptPA, you can submit both pharmacy and medical benefit drug prior authorization requests using the same platform. Through online submission, you can easily view drug specific criteria questions, attach clinical information, and receive a response more quickly.

We also encourage the use of electronic prior authorization (ePA) through EMR, CoverMyMeds, or Surescripts. Alternatively, you can submit prior authorization requests via FAX using the corresponding request forms. Updated forms — with new fax numbers — will be available in the pharmacy sections of our provider websites by to Jan. 1.

For more information on our pharmacy program, refer to our Quick Reference Guide with an overview of what to expect in 2023.

Beginning Jan. 1, you’ll be able to access PromptPA on our secure portal, HPHConnect. Look for more on PromptPA in future issues of Network Matters.

Changes to note for Commercial Members
While you should refer to formularies and pharmacy medical necessity guidelines for complete information, the following is an overview of some key changes that take effect on Jan. 1, 2023 for Commercial members. For information on specific pharmacy program changes for StrideSM (HMO)/(HMO-POS) Medicare Advantage, please refer to the dedicated Stride article in this newsletter. Commercial changes include:

  • Tier changes & low-cost generic drugs — Certain drugs are changing tiers (higher or lower tier) or will move to non-formulary status. In particular, tier changes were applied to low-cost generic drugs. We encourage providers to refer to the formulary for lower copay alternatives, when available.
  • Vaccine access — The only vaccines available through pharmacies will be: COVID, influenza, and Shingrix vaccines. All preventive vaccines are covered under the medical benefit.
  • Exclusions — The following will be excluded from the pharmacy benefit:
    • Drug Efficacy Study Implementation (DESI) drugs assigned code 5 or 6 by the Centers for Medicare and Medicaid Services (i.e., drugs that are not approved as safe and efficacious)
    • Bulk chemicals
    • Surgical supplies
    • General anesthetics (including midazolam injection and oral syrup)
    • Coverage of repackaged products, clinic packs, and institution packs
    • Medical benefit drugs
  • Long-acting opioids — We will require prior authorization for all long-acting opioids for Commercial members initiating a new course of treatment. Members who are currently taking a long-acting opioid will not require an authorization for those medications until Sept. 30, 2023. For criteria, refer to the Pharmacy Medical Necessity Guidelines for Opioid Analgesics.
  • Authorization for ADHD medications for members age 25 and older – We will require prior authorization for all stimulant medications used to treat attention deficit hyperactivity disorder (ADHD) for Commercial members 25 years and older who are newly starting these medications. Examples of these medications include, but are not limited to, amphetamine salts, methylphenidate, and Vyvanse. For criteria, please refer to the Pharmacy Medical Necessity Guidelines for Attention Deficit Hyperactivity Disorder Drugs.
  • Drugs Moving to Non-Formulary Status — We will no longer cover brand medications with interchangeable generics and select brand name medications with therapeutic alternatives. Please refer to the formulary for complete information. For brand-name drugs moving to non-formulary status, generic equivalents, if available, will remain covered. For a patient to continue one of these non-formulary medications, the prescribing provider must request coverage as an exception through the medical review process subject to the Medical Necessity Guidelines for Non-Formulary Exceptions.
  • Changes in Utilization Management (UM) Programs — Changes include requiring prior authorization and step-therapy for certain drugs. Prior authorization is being added to a number of drugs/drug classes, including, but not limited to, the following commonly utilized drugs:

Prior Authorization Required for Commercial Members as of Jan. 1, 2023

  • Acne Agents: Adapalene, Tazarotene, Tretinoin Products
  • ADHD Stimulants for members aged 25 and older (new starts only)
  • Antidepressants For Members Aged 12 And Younger (new starts only)
  • Antipsychotics: Symbyax, Lybalvi, Rexulti
  • Aspirin-Omeprazole Tab Delayed Release
  • Bylvay
  • Denavir Cream
  • Dificid
  • Doxycycline Cap 40mg
  • Doxylamine/Pyridoxine
  • Drugs For Parkinson’s Disease: Inbrija, Kynmobi, Apokyn, Rytary
  • Endocrine Agents; Myfembree, Synarel
  • Febuxostat
  • Gattex
  • Hepatitis C Drugs
  • HSDD Medications: Vyleesi, Addyi
  • Juxtapid
  • Kerendia
  • Korlym
  • Lidocaine Patches 5% (new starts only)
  • Livmarli
  • Livtencity
  • Metformin Extended Release
  • Mircera
  • Mulpleta
  • Non-Preferred Insulins: Soliqua
  • Nuedexta
  • Ocaliva
  • Ophthalmic Agents: Bimatoprost, Zioptan, Travatan, Rhopressa, Rocklatan
  • Long-acting opioid Analgesics (new starts only)
  • Oral Antifungals
  • Oral Oncology Drugs: Flutamide, Zykadia, Scemblix, Taflinar, Zelboraf, Nexavar, Caprelsa, Mekinist (new starts only)
  • Proton Pump Inhibitors (PPIs): select formulations
  • Ravicti
  • Relistor
  • Reyvow
  • Rezurock 200mg
  • Sedative Hypnotics
  • Sirturo
  • Tavneos
  • Testosterone Products
  • Topical Corticosteroids: Amcinonide, Clobetasol, Desonide, Desoximetasone, Diflorasone, Fluocinolone, Cordran, Fluticasone, Halcinonide, Halog, Lexette, Halobetasol, Etc. (new starts only)
  • Uptravi
  • Viberzi
  • Wakefulness Agents: Xywav
  • Xifaxan
  • Xolair
  • Zorbtive
  • Zubsolv

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

Joseph O’Riordan,

Kristin Edmonston,
Production Coordinator