Harvard Pilgrim Health Care Coverage Criteria
- Harvard Pilgrim Health Care prior authorization
- Harvard Pilgrim Health Care timely filing
- All Harvard Pilgrim Health Care policy updates
Latest Harvard Pilgrim Health Care coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-11Akynzeo (netupitant/palonosetron) prior authorizationPrior authorization criteria for coverage of Akynzeo (netupitant/palonosetron) for prevention of chemotherapy-induced nausea and vomiting in adult members of Harvard Pilgrim and Tufts commercial products.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-11Onapgo (apomorphine) and Vyalev (foscarbidopa/foslevodopa) - Prior AuthorizationPrior authorization policy for coverage of Onapgo (apomorphine hydrochloride) and Vyalev (foscarbidopa/foslevodopa) for adults with advanced Parkinson's disease under Harvard Pilgrim and affiliated Tufts commercial and specified public products.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Adalimumab products — Prior authorization and medical necessityThis guideline governs prior authorization and medical necessity criteria for coverage of adalimumab products (including multiple biosimilars and brands) for Harvard Pilgrim and affiliated commercial products; it applies to prescribers seeking coverage for members under the listed commercial and public plan products.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Applied Behavioral Analysis (ABA) therapy coverage — Clinical/Medical Policy (Coverage Criteria)Defines medical necessity, prior authorization, coding, and limits for Applied Behavioral Analysis (ABA) services for applicable Harvard Pilgrim and Tufts commercial products and Tufts Health Direct; includes coverage for ASD and, in Massachusetts products, Down syndrome when criteria are met.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Foot reconstruction procedures: bunionectomy and hallux valgus correction — Medical Necessity GuidelineThis medical necessity guideline governs prior authorization requirements and coverage criteria for foot reconstruction procedures (fifth metatarsal osteotomy, proximal phalanx osteotomy of the first toe, and first MTP joint arthrodesis) for Harvard Pilgrim and affiliated Tufts commercial/public products.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Gender‑Affirming Services — Coverage Criteria and Medical NecessityCoverage criteria and medical necessity requirements for gender-affirming medical and surgical services for Harvard Pilgrim Health Care and related Tufts/Point32Health products, including adults and members under 18. Specifies which procedures are considered medically necessary, required documentation, limitations, and prior authorization notes.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Prior Authorization Medical Necessity Guidelines — Part 1 (drug-specific PA rules)This document lists prior authorization medical necessity criteria for multiple pharmacy and specialty drug products and defines required documentation, prescriber restrictions, coverage durations, and prerequisite therapy requirements for Harvard Pilgrim Health Care members.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Therapeutic apheresis (plasmapheresis/TPE) — Coverage CriteriaDefines medical necessity criteria and coding for therapeutic apheresis (including plasmapheresis, plasma exchange, and immunoadsorption) for Harvard Pilgrim Health Care commercial products. Applies to clinical requests for apheresis procedures and describes covered indications and limitations.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Tufts Medicare Preferred Prior Authorization Medical Necessity Guidelines (drug-specific PA rules)Compilation of prior authorization and medical necessity criteria for numerous pharmacy and specialty drugs describing required diagnoses, prescriber restrictions, prerequisite therapies, monitoring, and coverage durations where specified.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-12Actimmune (interferon gamma-1b) prior authorizationDefines prior authorization criteria for coverage of Actimmune for members of Harvard Pilgrim Health Care and affiliated Tufts commercial products, covering indications of Chronic Granulomatous Disease and severe malignant osteopetrosis and who may prescribe it.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Prior Authorization Medical Necessity Guidelines — Pharmacy & Specialty DrugsDefines prior authorization medical necessity criteria for many specialty and pharmacy drugs, including required medical information, prescriber restrictions, coverage duration, and prerequisite therapy requirements for Harvard Pilgrim Health Care members.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Actemra (tocilizumab) subcutaneous — Prior Authorization Coverage CriteriaPrior authorization criteria for coverage of Actemra (tocilizumab) subcutaneous across Harvard Pilgrim and Tufts commercial products; includes initial and reauthorization requirements, program-level limits, and formulary preference updates.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Adalimumab products prior authorizationDefines Harvard Pilgrim Health Care prior authorization and medical necessity criteria for coverage of adalimumab products (multiple biosimilars and brands) across specified inflammatory indications for commercial and specified public plan products.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Applied Behavioral Analysis (ABA) Therapy — Coverage CriteriaAll harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01AposTherapy foot‑worn biomechanical device — medical necessity guidelineMedical necessity guideline for use of the AposTherapy foot‑worn biomechanical device to treat adults with chronic knee osteoarthritis or chronic low back pain for Harvard Pilgrim Health Care commercial products.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Adalimumab products prior authorizationDefines prior authorization and medical necessity criteria for coverage of branded and biosimilar adalimumab products for Harvard Pilgrim / Tufts commercial and select public plan members.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Adstiladrin (nadofaragene firadenovec-vncg) — Coverage Criteria for BCG‑unresponsive NMIBC with CISMedical necessity guideline for prior authorization and coverage of Adstiladrin for adults with high‑risk, BCG‑unresponsive non‑muscle invasive bladder cancer (NMIBC) with carcinoma in situ (CIS), applicable to the Plan's covered products and subject to benefit terms.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Anterior Vertebral Body TetheringDefines medical necessity criteria, limitations, and prior authorization requirement status for anterior vertebral body tethering (AVBT) for idiopathic scoliosis in skeletally immature patients across Harvard Pilgrim/Tufts products. Lists CPT/HCPCS codes requiring prior authorization and describes provider/facility qualifications.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Applied Behavior Analysis (ABA) services — Coverage CriteriaDefines medical necessity, admission, continuing stay, and discharge criteria for ABA services for members (primarily under age 21) with Autism Spectrum Disorder or Down Syndrome, and describes settings, treatment intensity, and exclusions relevant to authorization decisions.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Applied Behavioral Analysis (ABA) therapy coverage criteriaPolicy governing prior authorization and coverage criteria for Applied Behavioral Analysis (ABA) services for members with Autism Spectrum Disorder (ASD) and Down syndrome for applicable commercial and certain public plans in Massachusetts and participating Tufts/Harvard Pilgrim products.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Direct 3-Tier Prescription Drug List (Formulary Coverage Criteria)Defines the Direct 3-Tier formulary, coverage indicators, and pharmacy benefit management processes; includes tier assignments, utilization management flags (PA, ST, QL, NTM), specialty pharmacy routing and site-of-care limitations for members and providers.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Tufts Health Plan Direct 3-Tier Prescription Drug List (Formulary) - Coverage CriteriaDefines the Direct 3-Tier formulary structure, coverage indicators, and pharmacy benefit management processes including tier placements, prior authorization, step therapy, quantity limits, specialty pharmacy and site-of-care restrictions for members and providers.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Allergy immunotherapy (sublingual and oral immunotherapy) coverageDefines medical necessity criteria and authorization requirements for coverage of FDA-approved sublingual immunotherapy tablets (Oralair, Odactra) and oral peanut immunotherapy (Palforzia) for applicable Harvard Pilgrim members; excludes Medicare members.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-01Biomarker testing for Alzheimer disease (CSF and specified plasma assays)Defines coverage for cerebrospinal fluid and specific plasma biomarker tests for individuals with suspected Alzheimer disease or mild cognitive impairment for Harvard Pilgrim Health Care commercial products.All harvard pilgrim health care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-01Cervical cancer screening — coverage criteriaPolicy governing coverage of cervical cancer screening tests (Pap cytology, high-risk HPV testing, and co-testing) for individuals with a cervix under Harvard Pilgrim Health Care commercial products.All harvard pilgrim health care updates
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Tool Description
Search Harvard Pilgrim Health Care coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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