For 2024, Point32Health will not be refreshing tier assignments for the Harvard Pilgrim’s ChoiceNet HMO and PPO plans; all provider tier classifications will remain consistent with classifications for the 2023 plan year.
When billing for HIV PrEP and other related services, please bill in accordance with our Harvard Pilgrim Patient Protection and Affordable Care Act (Federal Health Care Reform) policy and Tufts Health Plan Preventive Services Payment Policy.
Effective for dates of service beginning Nov. 1, 2023, Point32Health will require that providers billing for Spravato (esketamine) nasal spray for Harvard Pilgrim commercial members include HCPCS code G2082 or G2083 on the medical claim, in addition to HCPCS code S0013, which will also continue to be required.
Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.
As a reminder, Harvard Pilgrim commercial members who are currently taking a long-acting opioid and who have not had a clinical review completed will require authorization on or after Nov. 1, 2023.
We want to provide you with an update on our plans to insource our behavioral health program for Harvard Pilgrim commercial members, which will now be taking place on Nov. 1, 2023.
As part of ongoing efforts to review prior authorization requirements and reduce administrative burden, Harvard Pilgrim Health Care is removing prior authorization requirements for insulin infusion pumps and home infusion administration for commercial members.
Effective for dates of service beginning Oct. 1, 2023 for Harvard Pilgrim commercial members, providers must request a new authorization for home care and hospice services that extend beyond the end date of the existing authorization.
Point32Health utilizes InterQual criteria for clinical authorization review for a number of services. For the Medical Necessity Guidelines listed here, we will be adopting 2023 InterQual SmartSheets to replace the previous versions currently in use.
In a continued effort to reduce prior authorization burden on providers and members, effective Sept. 1, 2023 these drugs will no longer require prior authorization through OncoHealth for oncology indications for members of Harvard Pilgrim’s commercial and Stride Medicare Advantage plans.
Effective for fill dates on or after Jan. 1, 2024, Harvard Pilgrim Health Care Commercial Plans, Tufts Health Plan Commercial Plans and Tufts Health Plan Direct will only cover prescription generic prenatal vitamins on our pharmacy formulary.
Effective Oct. 1, 2023, the identified generic inhaler products will not be covered in the formularies for Harvard Pilgrim Health Care commercial, Tufts Health Plan commercial and Tufts Health Direct. Alternative NDCs for the same drug, and similar agents, are covered on our formularies.
As a reminder, Harvard Pilgrim commercial members who are currently taking a long-acting opioid and who have not had a clinical review completed will require authorization on or after Nov. 1, 2023.
Effective immediately, any products listed on the Harvard Pilgrim Health Care commercial, Tufts Health Plan commercial, and Tufts Health Direct formularies that have not been approved by the FDA will be excluded from coverage, in alignment with the information listed on our Evidence of Coverage documents and Member Handbooks.
Updates to Harvard Pilgrim’s standard home care seasonal influenza vaccine fee schedule will take effect on Aug. 1, 2023. To request an updated fee schedule, please call the Provider Service Center at 800-708-4414.
Review this chart for updated Pharmacy Medical Necessity Guidelines with changes effective August 1, 2023 for Point32Health’s Pharmacy drug prior authorization program.