harvard pilgrgrim pharmacy prior auth & coverage

Coverage & Eligibility Rules

Supply and formulary-based coverage

Covered when plan-specific supply and formulary rules are met.

Supply limits by plan: Tufts Health RITogether: up to a 30-day supply at retail for most medications; voluntary 90-day program for select generic maintenance medications; contraceptives up to a 365-day supply (including initial fill). Tufts Health Together: up to a 30-day supply for most medications except those in MassHealth's 90-day program; up to a 60-day supply for dextroamphetamine or methylphenidate for ADHD/narcolepsy; contraceptives up to a 365-day supply. Tufts Health Direct: up to a 60-day supply for dextroamphetamine or methylphenidate for ADHD/narcolepsy; up to a 90-day supply for maintenance medications when filled at retail or mail-order; contraceptives up to a 365-day supply following an initial fill.

Supply and specific drug inclusion depend on the PDL/formulary or MassHealth Drug List.

Authorization-based coverage

Covered when prior authorization or step therapy requirements are satisfied.

Prior authorization: Drugs designated on the PDL, formulary, or MassHealth Drug List require prior authorization per the Pharmacy Medical Necessity Guidelines. Providers must submit PA requests electronically via PromptPA (provider portal), ePA, fax, or mail to the Pharmacy Utilization Management Department; determinations are made within specified timeframes (urgent and standard timelines described in the guidelines).

If denied, provider may appeal per rights and responsibilities.

Step therapy is an automated prior authorization using claims history at point of sale; it requires trial of preferred first-line therapies per protocol. If a member lacks the required claims history, the claim will deny with a message that prior authorization is required and providers may submit a utilization review request. For Tufts Health Direct members stable on a step therapy drug, a one-time transition fill up to 30 days is allowed while an exception is reviewed.30 days

Step therapy protocols are based on clinical guidelines, FDA labeling, and cost; exceptions and appeals timelines follow state requirements (including expedited timelines).

Excluded or restricted products

Non-coverage or restricted coverage conditions.

New-to-market drugs are reviewed by the P&T Committee before being added to the PDL or formulary. For Tufts Health Together, new drugs remain new-to-market until MassHealth adds them to the MassHealth Drug List. For Tufts Health Direct, new products are excluded from coverage until reviewed by the P&T Committee (interim exclusion lasts until the earlier of Dec. 31 of the following calendar year or as required by law). Providers may submit utilization review requests for medical necessity during the interim.

Interim utilization review requests may be submitted for medical necessity.

Exclusions: Excluded products include: medications used for cosmetic purposes (unless medically necessary), medications for sexual dysfunction (for Together, RITogether and One Care), certain cough and cold medications (Tufts Health Together), contraceptive implants (Tufts Health Direct and RITogether), experimental/investigational drugs, infertility agents (in certain plans), over-the-counter medications not on the Tufts Health Direct formulary, medical supplies, digital therapeutics/PDTs unless covered, drugs not FDA-approved, and DESI drugs. New-to-market medications for Tufts Health RITogether are also excluded until P&T review.

Some exclusions reference plan- or state-specific protocols and MassHealth rules.

Coverage Rules

Coverage and access rules.

New-to-Market Drugs: Tufts Health Together: new drugs remain new-to-market until MassHealth adds them to the MassHealth Drug List. Tufts Health Direct: new-to-market products are excluded from coverage until P&T Committee review is complete (interim exclusion until the earlier of Dec. 31 of the following calendar year or as required by law). Providers may submit utilization review requests for medical necessity during the interim.

Providers should contact Provider Services for coverage status and may request utilization review.

Quantity Limits: Quantity limitations restrict the covered amount of a drug in a given time period based on recognized standards of care (e.g., FDA recommendations). Providers may request exceptions via the utilization review process if greater quantities are medically necessary.

See quantity limitations program for details.

Specialty Pharmacy Dispensing: Designated specialty pharmacy program supplies select complex-disease drugs through Optum Rx Specialty pharmacy (UMass Memorial Specialty Pharmacy required for certain ACO members). For medications in the specialty program, providers may prescribe up to a 30-day supply through Optum Rx Specialty pharmacy. Specialty medications provided by Optum Rx Specialty are not covered through retail, other specialty, or mail-order pharmacies.

Tufts Health Plan does not cover certain categories of medications under the pharmacy benefit. Exclusions include: medications used for cosmetic purposes (unless medically necessary); medications for sexual dysfunction (for Tufts Health Together, Tufts Health RITogether and Tufts Health One Care members); cough and cold medications for Tufts Health Together members; contraceptive implants for Tufts Health Direct and Tufts Health RITogether; experimental or investigational drugs; infertility agents for specified plans; over-the-counter medications not listed on the Tufts Health Direct formulary; medical supplies; digital therapeutics and prescription digital therapeutics (PDTs) unless specifically listed for the member's plan; drugs not approved by the FDA; and Drug Efficacy Study Implementation (DESI) drugs.

New-to-market products are subject to plan review before being added to the PDL or formulary. For Tufts Health RITogether and Tufts Health One Care, new products are reviewed by the P&T Committee prior to inclusion. For Tufts Health Together, products remain new-to-market until MassHealth adds them to the MassHealth Drug List. Specialty pharmacy medications included in the designated SP program must be dispensed through the plan's specialty pharmacy (Optum Rx Specialty or UMass Memorial Specialty Pharmacy where applicable) and are not covered through retail, other specialty, or mail-order pharmacies.

Any drug or product not listed on the current Preferred Drug List (PDL) or formulary for Tufts Health RITogether, Tufts Health Direct, or Tufts Health One Care is treated as new-to-market or non-covered unless it meets a listed exclusion. Providers who believe a member has a medical necessity for a non-formulary product may submit a prior authorization request under the utilization review process to document medical necessity and request coverage.

A new drug product will be excluded from coverage during the P&T review process for Tufts Health Direct (the interim exclusion lasts until the earlier of Dec. 31 of the following calendar year or as required by law). Providers may submit a utilization review request to seek coverage for a member with medical need during this interim period; contact Provider Services with questions about coverage status.

Provider Submission, Prior Authorization, and Step Therapy

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain drugs listed in the Pharmacy Medical Necessity Guidelines and the PDL/formulary. Specialty medications that require prior authorization must follow the specialty prior authorization process described in the Pharmacy Medical Necessity Guidelines and specialty dispensing rules.

Submit PA requests electronically via PromptPA through the provider portal (https://point32health.promptpa.com) or via electronic prior authorization (ePA).
Fax or mail submissions to the Pharmacy Utilization Management Department — see payer-specific fax numbers and mailing address in the Pharmacy Medical Necessity Guidelines and provider materials.
For specialty medications, use the Optum Rx Specialty Enrollment form and send PA requests to the Pharmacy Utilization Management Department per the specialty PA fax numbers below.

Prior Authorization

Specialty Medication Prior Authorization

Specialty medications are dispensed through the designated specialty pharmacy program (Optum Rx Specialty pharmacy unless otherwise specified). Many specialty drugs are not covered through retail, other specialty, or mail-order pharmacies and require specialty PA submission and fulfillment through the specialty pharmacy.

Transition & Continuity of Therapy

Transition fills

Transitions and continuity rules for members already stable on therapy.

Transition fill for step therapy (Tufts Health Direct): When a Tufts Health Direct member is stable on a drug subject to step therapy, a one-time transition fill of up to a 30-day supply is allowed while an exception to the step therapy requirement is reviewed. Providers must contact Provider Services at 888-257-1985 to request the one-time transition fill.30 days

Step therapy exceptions and appeals must be processed within statutory timelines (3 business days after receipt of all necessary information; 24 hours for urgent requests).

Step Protocols and Requirements

Requirement	Detail
Trial of preferred first-line therapies per step protocol
Step therapy is an automated form of prior authorization that uses claims history for approval at the point of sale; if member lacks required claims history the prescription will deny at point of sale and prior authorization must be submitted via utilization review.
Step therapy protocols are based on current medical findings, FDA‑approved labeling, and drug costs; drugs are placed in step therapy when not considered first‑line or when cost is disproportionate compared with alternatives.
Members currently on drugs that meet initial step criteria may automatically fill their prescriptions; providers may submit prior authorization requests for exceptions.
Tufts Health Direct: members stable on a step therapy drug may receive a one‑time transition fill up to 30 days while an exception is reviewed.

Reference	Instruction / Source
Pharmacy Medical Necessity Guidelines (step therapy edits)
Follow the Pharmacy Medical Necessity Guidelines for specific step therapy requirements and step edits; refer to the PDL or formulary (or MassHealth Drug List for Tufts Health Together) for which drugs are included in step programs.
Specialty medication step therapy and prior authorization: for specialty drugs that require PA, refer to the Pharmacy Medical Necessity Guidelines and submit PA via ePA, fax, or mail to the plan‑specific Pharmacy Utilization Management fax/address listed in the Public Plans Provider Manual.
Specialty pharmacy dispensing and enrollment: use Optum Rx Specialty Enrollment form and send specialty prescriptions to Optum Rx Specialty pharmacy; specialty medications supplied through Optum Rx Specialty are limited to a 30‑day supply and are not covered through retail, other specialty, or mail‑order pharmacies.

Quantity Limit Policies

Unspecified program-level quantity limits — program-specified quantities based on standards of care

Program-level quantity limitsQuantities are program-specified and based on recognized standards of care (for example, FDA recommendations).

Exception processProviders may submit a request via the utilization review process when a member needs a quantity greater than the program limitation.

ScopeApplies to any drug or product covered under the pharmacy benefit where a quantity limit is defined.

specialty medications quantity limit — 30-day specialty quantity noted

Specialty medication quantity limitSpecialty medications in the designated SP program may be prescribed up to a 30-day supply through Optum Rx Specialty pharmacy.

Coverage restriction

Contact, Codes, and Specialty Fill Limits

Contact and submission linesmixed

844-265-1705	Optum Rx Specialty pharmacy phone
877-342-4596	Optum Rx Specialty Pharmacy fax
617-673-0939	Tufts Health Together and Tufts Health RITogether PA fax
617-673-0988	Tufts Health Direct PA fax
617-673-0956	Tufts Health One Care PA fax

specialty fill limit — maximum specialty fill through Optum Rx Specialty Pharmacy (30-day)

Maximum specialty fill via Optum RxMaximum specialty fill through Optum Rx Specialty Pharmacy is a 30-day supply per prescription.

Enrollment requirementUse the Optum Rx Specialty Enrollment form to request specialty medications.

Dispensing limitationSpecialty medications provided by Optum Rx Specialty are not covered if dispensed through retail, other specialty, or mail-order pharmacies.

Key Terms

PDL definition — Preferred Drug List definition for RITogether

Definition (PDL)Preferred Drug List (PDL): A list used by Tufts Health RITogether to promote appropriate and cost-effective outpatient prescription drug products.

ScopeThe PDL applies to medications or products members receive through retail and specialty pharmacies (if applicable) and does not apply to medications used in direct-care settings.

GovernanceThe PDL and other formulary decisions are reviewed and approved by the pharmacy and therapeutics (P&T) Committee and the drug coverage committee (DCC).

Formulary definition — Formulary definition for Tufts Health Direct & One Care

Definition (Formulary)Formulary: A listing of drugs that are considered preferred therapy for members within the pharmacy benefit of a managed health plan (used by Tufts Health Direct and Tufts Health One Care).

Development

Specialty Dispensing & Site of Care

Billing Rule

Specialty medications — dispense through Optum Rx Specialty Pharmacy

Specialty medications included in the designated specialty pharmacy program must be dispensed through Optum Rx Specialty pharmacy (UMass Memorial Specialty Pharmacy for applicable ACO members); providers should send specialty prescriptions to Optum Rx Specialty pharmacy and coordinate delivery and enrollment.

Optum Rx Specialty phone: 844-265-1705; fax: 877-342-4596.
Providers may prescribe up to a 30-day supply through Optum Rx Specialty pharmacy; medications provided by Optum Rx Specialty are not covered through retail, other specialty, or mail-order pharmacies.

Policy Governance & Committee Oversight

The P&T Committee and the Drug Coverage Committee evaluate new drugs and existing therapies for safety, efficacy, and cost-effectiveness and set prior authorization, step therapy, and quantity limit policies that determine PDL/formulary placement. Committee decisions drive which outpatient therapies are preferred or require utilization management, and specialty medications are assigned to the designated specialty pharmacy program when clinically appropriate.

OpenPayer

Pharmacy benefit program and prior authorization processes