Harvard Pilgrim pharmacy policy Prior Auth

Coverage, Formulary, and Exclusions

Formulary-based Coverage, New-to-Market, and Exclusions

Coverage and formulary application depend on the member's plan and the applicable PDL/formulary or MassHealth Drug List.

Formulary/PDL-based coverage: Drugs listed on the applicable PDL or MassHealth Drug List are subject to the coverage rules, prior authorization, quantity limits, and step therapy as specified on those lists.

Applies per plan (RITogether, Together, Direct, One Care)

New-to-market drugs are not added to the PDL/formulary until reviewed by the P&T Committee; for Tufts Health Together they remain new-to-market until MassHealth adds them to the MassHealth Drug List. Providers may submit a utilization review/prior authorization request if medical necessity exists during the interim.

Coverage determination delayed until P&T or MassHealth review

Exclusions: Specific drug categories (e.g., medications used for cosmetic purposes, sexual dysfunction agents, certain cough and cold medications for Tufts Health Together, experimental/investigational drugs, infertility agents for select plans, OTCs not on formulary, non‑FDA approved products, DESI drugs, and digital therapeutics/PDTs unless listed) are excluded from the pharmacy benefit per plan exceptions.

See exclusions list and plan-specific formularies/PDLs for details

Specialty Pharmacy Coverage

Covered when ALL of the following are met

Designated specialty pharmacy program: Medication is included in the designated specialty pharmacy (SP) program and is prescribed for an eligible member.

Specialty medications included in the SP program are managed through Optum Rx Specialty (UMass Memorial Health ACO members use UMass Memorial Specialty Pharmacy).

Specialty routing restriction: Medications that Optum Rx Specialty pharmacy provides are not covered through retail pharmacies, other specialty pharmacies, or mail-order pharmacies.

Use Optum Rx Specialty Enrollment form to request specialty medications; UMass Memorial ACO members must use UMass Memorial Specialty Pharmacy.

Supply limit: Provider prescribes a supply of medication that does not exceed the specialty program limit.<= 30 days

For medications included in the SP program, providers may prescribe up to a 30-day supply through Optum Rx Specialty pharmacy.

New-to-Market Drug Interim Coverage

Interim coverage allowed when ALL of the following are met

NTM interim request: Provider submits a utilization review request asserting medical necessity for a new-to-market drug or product prior to P&T Committee or MassHealth review.

Coverage determination for new-to-market drugs is delayed until P&T Committee or MassHealth review; contact Provider Services for coverage status while pending.

Tufts Health Plan excludes certain categories of medications from coverage under the pharmacy benefit. Notable exclusions include medications used for cosmetic purposes (unless medically necessary per cited rules), medications for sexual dysfunction (for Tufts Health Together, Tufts Health RITogether and Tufts Health One Care), and cough and cold medications for Tufts Health Together members. The plan also excludes experimental or investigational drugs, drugs not approved by the FDA, Drug Efficacy Study Implementation (DESI) drugs, and many new-to-market medications for Tufts Health RITogether until reviewed by the P&T Committee. Other exclusions include infertility agents for Together/RITogether/One Care members, over‑the‑counter products not listed on the Tufts Health Direct formulary, medical supplies, and digital therapeutics/PDTs unless specifically covered on plan lists.

Medications designated for the specialty pharmacy program must be dispensed through the plan’s designated specialty provider. Tufts Health Plan offers its specialty program through Optum Rx Specialty pharmacy (with exceptions such as UMass Memorial Health ACO members who must use UMass Memorial Specialty Pharmacy). For drugs included in the specialty program, providers may prescribe up to a 30‑day supply through Optum Rx Specialty. Medications supplied by Optum Rx Specialty are not covered if dispensed through retail pharmacies, other specialty pharmacies, or mail‑order pharmacies. Providers must use the Optum Rx Specialty Enrollment form to request specialty medications.

Any drug or product not listed on the current PDL or formulary for Tufts Health RITogether, Tufts Health Direct, or Tufts Health One Care is considered new‑to‑market or non‑covered unless it meets an exclusion. The plan treats such items as non‑covered when there are safe, comparably effective, and less expensive alternatives available. In those cases a prior authorization under the utilization review process is required for the plan to consider coverage based on documented medical necessity.

Maximum Supply Limits and Coding Notes

Maximum supply limits by plan

Tufts Health RITogether - standard retail supplyUp to a 30-day supply of most medications at retail (voluntary 90-day program exceptions listed elsewhere)

Tufts Health Together - standard retail supplyUp to a 30-day supply of most medications, except drugs in MassHealth's 90-day supply program

Tufts Health Direct - maintenance and specific agentsUp to a 90-day supply for maintenance medications at retail or mail-order; up to 60-day supply for dextroamphetamine or methylphenidate; contraceptives up to 365-day following initial fill

Prior Authorization, Step Therapy, and Provider Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for select drugs and products listed on the PDL/formulary or MassHealth Drug List. To request a pharmacy prior authorization, refer to the Pharmacy Medical Necessity Guidelines for the specific drug prior authorization requirements. Requests may be submitted electronically through PromptPA via the provider portal (https://point32health.promptpa.com), or via electronic prior authorization (ePA), fax, or mail to the Pharmacy Utilization Management Department. Notification of the decision to approve or deny the request will be made via mail or fax. If denied, an alternate therapy may be recommended and providers may appeal per the Rights and Responsibilities chapter.

PromptPA/provider portal: https://point32health.promptpa.com
ePA, fax, or mail submission accepted
Decision timelines: Tufts Health Together and Tufts Health RITogether — within 24 hours for urgent; Tufts Health Direct — within 48 hours (no longer than 72 hours if additional info needed) for urgent; standard requests: within 2 business days (no longer than 15 days if additional info needed)

Key Definitions

PDL/Formulary — definition and role

DefinitionPreferred Drug List (PDL) or formulary: a listing of drugs considered preferred therapy within the pharmacy benefit that includes coverage rules such as prior authorization, quantity limits, and step therapy.

Role in coverage decisionsDrugs listed on the applicable PDL/formulary or MassHealth Drug List are subject to coverage rules, PA, QL, and ST; inclusion is determined by the P&T and Drug Coverage Committees.

Updates and accessComplete lists of covered drugs, including specialty drugs in the SP program, are available on the provider website and communicated via provider channels.

Specialty Pharmacy — definition

DefinitionSpecialty Pharmacy: a designated program that supplies select drugs for complex disease states and is staffed with nurses, coordinators, and pharmacists to provide member support.

Program routing

Continuation and Transition of Therapy

Step Therapy Continuation/Transition

Transition and continuity provisions when members are stable on therapies subject to step therapy.

Members stable on step therapy agents: Members who are currently on drugs that meet the initial step therapy criteria will be able to fill their prescriptions without meeting prior step history at point of sale.

If member lacks required claims history, the prescription will deny at point of sale with an instruction to submit prior authorization via utilization review.

One-time transition fill (Tufts Health Direct): For Tufts Health Direct members who are stable on a drug subject to step therapy, allow a one-time transition fill while an exception is reviewed.<= 30 days

Providers must contact Provider Services at 888-257-1985 to request the one-time transition fill; exceptions and appeals must be processed within regulatory timelines (3 business days for standard, 24 hours for urgent when additional delay poses significant risk).

Step Therapy Enforcement and Process

At point-of-sale	Claim outcome / message	Provider action
Member meets step therapy criteria per claims history
Claim approves at point-of-sale
No action required; member may fill medication

Situation	Transition / continuity policy	How to request exception or PA
Member currently stable on therapy that is subject to step therapy
Members currently on drugs that meet initial step therapy criteria will automatically be able to fill their prescriptions; Tufts Health Direct allows a one-time transition fill (up to 30 days) while exception is reviewed
Providers may submit a prior authorization or utilization review request to Tufts Health Plan when member lacks required claims history or to request continuation/transition fill

Quantity Limits and Specialty Supply

Quantity limit program — standards and exception process

Program basisQuantity limits are established based on recognized standards of care, such as FDA recommendations for use.

Exception processIf a provider believes a member needs a quantity greater than the program limitation, a request can be submitted under the utilization review process.

Denial riskRequests exceeding quantity limitations may be denied unless an exception is approved through utilization review.

Specialty medications — supply limits and routing

Specialty medication supply through SPFor medications included in the designated specialty pharmacy program, providers may prescribe up to a 30-day supply through Optum Rx Specialty pharmacy.

Other specialty limits

Specialty Pharmacy Site-of-Care and Delivery

Note

Optum Rx Specialty delivery and 24/7 pharmacist support

Optum Rx Specialty pharmacy will deliver specialty medications to a member's home (not a P.O. Box) or a clinician's office and provides access to staff pharmacists 24 hours a day, seven days a week for counseling and support.

Optum Rx Specialty phone: 844-265-1705
Optum Rx Specialty fax: 877-342-4596

Policy Governance and Committees

Tufts Health Plan uses a Pharmacy & Therapeutics (P&T) Committee and Drug Coverage Committees to evaluate the safety, efficacy, and cost‑effectiveness of drugs before adding them to the PDL/formulary. New products, clinical evidence, and cost considerations are reviewed by these committees to determine formulary placement, any prior authorization, step therapy, or quantity‑limit requirements, and whether interim coverage is appropriate while formal review is pending.

OpenPayer

Pharmacy benefit management, formulary/PDL use, prior authorization, step therapy, quantity limits, and specialty pharmacy procedures