CommercialPrior AuthMedium impact
Pharmacy coverage changes
Harvard Pilgrim Health Care·Endocrinology, Genetics, Family Medicine +2 more·Pharmacy
Effective date
May 1, 2026
We identified it
Jun 20, 2026
Summary
Point32Health (Harvard Pilgrim and Tufts Health Plans) updated pharmacy medical necessity guidelines effective 5/1/26. Key changes include new specialist prescribing requirements for Imcivree, removal of step therapy for diabetes medications (now requiring prior authorization), and updated approval durations for non-formulary insulin and growth hormone products.
Action Required
Before May 1, 2026: Update prior authorization workflows for diabetes medications (Bydureon BC, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity) as step therapy is removed and replaced with prior auth requirements. Ensure Imcivree prescriptions come only from endocrinologists, geneticists, or metabolic disorder specialists. Update EMR templates to reflect new approval duration requirements for non-formulary insulin and growth hormone products.