We want to make you aware of upcoming changes in coverage related to weight loss medications, as part of our efforts to provide access to the most appropriate health care options while managing rising pharmacy costs.
As you know, health plans conduct medical record review programs to ensure accurate billing, coding, and documentation practices and compliance with requirements.
We are implementing a new laboratory benefit management program for Harvard Pilgrim Health Care Commercial products, effective for dates of service beginning Nov. 1, 2025.
Beginning Oct. 1, 2025, Evolent will be conducting utilization management for spine and interventional pain management services for Tufts Medicare Preferred members.
SNFs: submit a Status Change Form (SC-1) promptly to MassHealth and Tufts Health Plan when a SCO or One Care member is admitted for a stay of two months or longer.
All provider tier classifications for Harvard Pilgrim’s ChoiceNet HMO and PPO plans will remain the same for the 2026 plan year.
Beginning Sept. 1, 2025, we will be reimbursing behavioral health urgent care centers for a core set of outpatient services using a bundled encounter rate per member per date of service.
HEDIS has expanded their recommended age range for breast cancer screenings to ages 40 through 74.
We encourage providers to include relevant ICD-10 Z codes to help recognize members who are experiencing social problems that could adversely affect their health.
With the flu season approaching, providers are reminded that they play a vital role in informing patients and addressing misconceptions about vaccination efficacy.
Tufts Health Plan Senior Care Options (SCO) PCPs and specialists are reminded to complete the new 2025 SCO Model of training by the end of 2025.
Providers are reminded to discuss the importance of, and regularly test for, blood glucose and cholesterol levels with patients taking antipsychotic medications.
Point32Health has interpretation services for hundreds of languages that can assist providers with communication for non-English-speaking patients.
We’re pleased to share some new resources related to prenatal and postpartum care from MassHealth for providers and members.
For Tufts Health RITogether members, Yesintek will be added to the formulary at a preferred status, while Stelara and all biosimilars will be designated as non-preferred and non-formulary.
Providers should be aware that updated coverage and criteria for the MassHealth Unified Formulary will be available on or after Nov. 17, 2025.
The following chart outlines changes and new information on updated Payment Policies.
Providers and office staff can refer to the chart with updates to our medical benefit drug program.
Providers and office staff can refer to the following chart with updates for Pharmacy Medical Necessity Guidelines.