Insights and Updates for Providers

October 2023

Step Therapy Protocols and Exceptions

Harvard Pilgrim and Tufts Commercial  |  Tufts Health Direct  |  Tufts Health Plan Commercial  |  Tufts Health Plan SCO-Medicaid Only Plans  |  Tufts Health Together

Massachusetts law states that the clinical review criteria used to establish a step therapy protocol cannot require members to utilize a medication that is not likely to be clinically effective for the prescribed purpose. Mandatory exceptions in step therapy protocols are now required.

Update on commercial migration: MA and RI markets

Commercial products

Point32Health’s work of offering a more unified product portfolio for our commercial markets business will continue on a rolling basis throughout 2025, and includes transitioning Tufts Health Plan commercial members in Rhode Island to one of Harvard Pilgrim’s comparable commercial products beginning Jan. 1, 2024.

New HEDIS® tip sheets now available

All products

Point32Health is pleased to share that we have developed new tip sheets related to the Kidney Health Evaluation for Patients with Diabetes (KED), Controlling High Blood Pressure (CBP, and Transitions of Care (TRC) HEDIS® measures.

Help us keep directory information up to date

All products

The Centers for Medicare & Medicaid Services and other regulatory bodies, as well as the federal No Surprises Act of 2021, require health plans to maintain and update data in provider directories — and we rely on providers to review their data and notify us of changes as they happen to ensure that members have access to accurate information.

Inform Point32Health if you offer concierge medicine services

Harvard Pilgrim Health Care Commercial  |  Harvard Pilgrim Stride (HMO) Medicare Advantage  |  Tufts Health Plan Commercial  |  Tufts Medicare Preferred

Point32Health would like to remind any providers who are planning to offer concierge medicine services to eligible members that you are required to provide Point32Health at least 90 days’ advance notice prior to establishing a concierge-style practice.

Well-child visits and vaccines for adolescents

All products

Teenagers, like younger children, greatly benefit from regular check-ups and vaccinations, and these appointments are recommended annually for patients between ages 12-21. These visits allow providers to assess their overall well-being, address risky behaviors, and detect conditions which could affect the teens’ future development.

Register for a claims consultation event near you!

All products

Point32Health is delighted to share that we’re expanding our claims consultation series as part of our ongoing commitment to collaborating with our valued provider partners, and will be hosting events in October and November in Providence, RI; Canton, MA; Manchester, NH; Rocky Hill, CT; and Biddeford, ME.

Introducing Our Chief Medical Officer Glenn Pomerantz, MD, JD

All products

Point32Health has appointed Glenn Pomerantz, MD, JD as our new Chief Medical Officer. He oversees clinical innovation, quality and accreditation, medical policy, and the Harvard Pilgrim Health Care Institute, which includes the Department of Population Medicine at Harvard Medical School.

Tips for avoiding unnecessary denials


We are committed to ensuring that providers have an optimal experience when submitting claims for CareLink members. Through ongoing monitoring and review, we’ve compiled a list of reminders to help avoid common unnecessary claim denials and rejections.

2024 Part B Step Therapy program

Harvard Pilgrim Stride (HMO) Medicare Advantage  |  Tufts Health Plan Senior Care Options  |  Tufts Health Unify  |  Tufts Medicare Preferred

Effective for fill dates on or after Jan. 1, 2024, the following coverage requirements will apply to the Part B Step Therapy program for Harvard Pilgrim Stride (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Senior Care Options, and Tufts Health Unify.

Synagis coverage for the 2023-2024 RSV season

Harvard Pilgrim Health Care Commercial  |  Tufts Health Direct  |  Tufts Health Plan Commercial  |  Tufts Health RITogether

Point32Health would like to remind providers of our policy regarding Synagis (palivizumab), an injection of antibodies used to protect high-risk infants from severe respiratory syncytial virus (RSV) disease, for the 2023-2024 season.

Coverage updates – inhaled corticosteroids

Tufts Health Together

Brand name Flovent HFA and Flovent Diskus will be discontinued at the end of 2023. MassHealth will continue to require prior authorization for the authorized generic of Flovent HFA, and will be making coverage updates in the inhaled corticosteroid inhaler class effective Dec. 4, 2023.

MassHealth updates to Unified Formulary

Tufts Health Together — MassHealth MCO Plan and ACPPs

MassHealth recently announced the following updates to the MassHealth Unified Formulary, effective Dec. 4, 2023. Changes include pharmacy products and medical drugs being added to the MassHealth Drug List, as well as new and updated prior authorization programs.

Preparing for Behavioral Health Insourcing

Harvard Pilgrim Health Care Commercial

In preparation for the launch of our integrated and insourced behavioral health program on Nov. 1, 2023, we are sharing several tools and resources with you.

Point32Health Medical Necessity Guideline updates

All products

Providers and office staff can refer to the following chart to review changes and updates to Point32Health’s Medical Necessity Guidelines (MNGs), information about newly developed MNGs, and more.

Point32Health medical drug program updates

All products

Providers and office staff can refer to the following chart to review changes and updates to Point32Health’s medical drug program, including information about prior authorization and coverage, updated MNGs, and more.

Integrated Point32Health payment policies

All products

As part of our overarching integration work as a combined company, Point32Health has developed the following integrated Point32Health Payment Policies.