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.

Pharmacy coverage changes

Harvard Pilgrim and Tufts Commercial  |  Tufts Health Direct  |  Tufts Health Plan Commercial  |  Tufts Health RITogether  |  Tufts Health Together

Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.

Pharmacy coverage changes

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

Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.

NIA vendor program code updates

Harvard Pilgrim and Tufts Commercial  |  Harvard Pilgrim Stride (HMO) Medicare Advantage  |  Tufts Health Plan Commercial  |  Tufts Health Public Plans

In the April issue of Insights and Updates for Providers, Point32Health announced a number of changes expected to take effect June 1, 2023 in relation to the medical necessity review and prior authorization program that National Imaging Associates, Inc. (NIA) oversees on our behalf for certain procedures.

GIC product updates effective July 1

Harvard Pilgrim and Tufts Commercial

Effective July 1, 2023, Point32Health is updating our Commercial Group Insurance Commission product offerings, which will include the custom products Harvard Pilgrim Quality HMO and Harvard Pilgrim Explorer POS.

New pilot program for select Harvard Pilgrim members

Harvard Pilgrim and Tufts Commercial

Point32Health is collaborating with Freespira, Inc. to offer a new, evidence-based pilot program, which is now available for eligible fully insured Commercial Harvard Pilgrim Health Care members ages 18 and over in Massachusetts, New Hampshire, and Maine.  

Reimbursement update for IEP services effective July 1

Harvard Pilgrim and Tufts Commercial  |  Tufts Health Direct  |  Tufts Health Plan Commercial  |  Tufts Health Together  |  Tufts Health Unify

Effective for dates of service beginning July 1, 2023, Point32Health will no longer provide reimbursement for claims submitted with modifiers TM and TR for services provided in conjunction with a student’s individualized education program.

Pharmacy coverage changes

Harvard Pilgrim and Tufts Commercial  |  Tufts Health Direct  |  Tufts Health RITogether

Please refer to this chart to review updates to pharmacy prior authorization programs applicable to Harvard Pilgrim Health Care and Tufts Health Plan products.