Insights and Updates for Providers

July 2024

Pharmacy coverage changes

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

Jan. 1, 2024 Pharmacy coverage changes for various Point32Health products.

Preferred oncology biosimilars for 2024

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

Preferred products for the bevacizumab, rituximab, and trastuzumab drug classes.

Other 2024 Pharmacy program updates

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

2024 Pharmacy updates: Harvard Pilgrim commercial, Tufts commercial, Tufts Health Direct.

Complex Care Management services

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

Point32Health provides care management services for adult and pediatric members.

About Our Chronic Condition Management Programs

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

Point32Health’s approach to chronic condition management through patient-centered care.

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

Providers who are planning to offer concierge medicine services to eligible members are required to provide advance notice.

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 Synagis (palivizumab) policy for the 2023-2024 season.

Important behavioral health insourcing information

Harvard Pilgrim Health Care Commercial

We’re pleased to be moving ahead with behavioral health insourcing effective Nov. 1, 2023 and have a number of resources to ensure behavioral health providers have all the information they need to begin caring for Harvard Pilgrim commercial members.

ChoiceNet: no tiering changes for 2024

Harvard Pilgrim Health Care Commercial

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.

Reminders and update: billing for PrEP and HIV services

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

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.

Billing requirements updated for Spravato nasal spray

Harvard Pilgrim Health Care Commercial

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.

Pharmacy coverage changes

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

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

Reminder: prior authorization for long-acting opioids

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

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.

Update on Behavioral Health insourcing

Harvard Pilgrim Health Care Commercial

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.

Update: Prior authorization on insulin pumps and home infusion

Harvard Pilgrim Health Care Commercial

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.

Update on authorization requests for home care and hospice

Harvard Pilgrim Health Care Commercial

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.

Migration to 2023 InterQual criteria

Harvard Pilgrim Health Care Commercial | Tufts Health Plan Commercial | Tufts Health Public Plans

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.

OncoHealth program update

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

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.

Prenatal vitamin coverage update

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

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.

Generic inhalers coverage update

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

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.

Reminder: Prior authorization for long-acting opioids

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

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.

FDA-unapproved product coverage update

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

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.