GLP-1 weight management medication coverage changes
Point32Health is making changes related to coverage of GLP-1 weight management medications, and will be designating Zepbound as the preferred product as of July 1, 2025.
Insights and Updates for Providers
May 2025
Carelon molecular diagnostic testing program update
Our vendor partner for molecular diagnostic testing, Carelon, is implementing an update effective Aug. 1, 2025 regarding defining its service dates.
Pharmacy coverage changes
Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.
GLP-1 weight management medication coverage changes
Point32Health is making changes related to coverage of GLP-1 weight management medications, as part of our efforts to provide access to the most appropriate and efficacious health care options while managing health care costs.
Claims editing platform updates
In an effort to consistently apply industry standard claims edits reflecting national correct coding and guidelines from state regulatory agencies, we’re making updates to align our claims editing platforms.
Prior authorization reminder: intensity-modulated radiation therapy
As a reminder, as of April 1 the previously announced continuity of care period has ended and a prior authorization must be obtained for all members starting IMRT prior to their course of treatment.
Pharmacy coverage changes
Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.
Insourcing chronic kidney disease care management
Chronic kidney disease care management services for Tufts Health Direct members will be insourced within Point32Health’s integrated care management program.
Pharmacy split fill program for select oral oncology drugs
Point32Health is implementing a pharmacy split fill program for select oncology drugs to improve medication adherence and reduce drug wastage.
Pharmacy coverage changes
Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.
Pharmacy coverage changes
Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.
Continued stay and inpatient level of care reviews
We’re sharing a reminder regarding continued stay reviews for DRG case rate admissions, and an update to our level of care review process for elective inpatient surgical procedures.
PPACA coverage policy updates for 2025
We’ve made minor updates to the Harvard Pilgrim Patient Protection and Affordable Care Act Policy, and we’ve developed equivalent policies for Tufts Health Plan Commercial and Direct.
Coverage for inpatient donor human milk
As of Nov. 21, 2024, Point32Health will now cover medically necessary inpatient donor human milk and donor human milk-derived products for members of certain Massachusetts plans.
Prior authorization requirements for cardiac services
Effective for dates of service beginning March 1, 2025, Point32Health and Evolent are adding prior authorization requirements for a number of additional cardiac services.
Pharmacy coverage changes
We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.
Orphan Drug Program launch
Point32Health is collaborating with OptumRx, our pharmacy benefit manager, to introduce a new Orphan Drug Program, available Jan. 1, 2025.
Billing for behavioral health boarding
We’ve clarified the billing requirements outlined in our payment policies pertaining to BH boarding, and have updated a BH boarding billing requirement for Tufts Health Direct.
Observation Stay Payment Policy and process change
Effective Jan. 1, 2025, Point32Health is making a change to our review process for short inpatient stays and observation services.
Pharmacy coverage changes
The following changes to Point32Health’s Pharmacy program take effect on Jan. 1, 2025, including prior authorization, drug status, and formulary updates for various products.
Removing certain drugs from white bagging program
Effective for dates of service beginning Jan. 1, 2025, certain medications will be removed from the Office-Administered Medical Drugs list.
Other 2025 Pharmacy program updates
We are providing pharmacy updates for the 2025 plan year regarding formularies, weight loss prescription drugs and diabetic GLP-1 coverage, and adalimumab.
2025 medical benefit step therapy program
The chart in this article outlines a new medical benefit step therapy program, which will be effective for fill dates on or after Jan. 1, 2025.
Expansion of cryopreservation and storage coverage
Our cryopreservation and storage benefit now includes coverage for ovarian tissue and testicular tissue, in addition to the previous coverage for sperm, eggs, and embryos.
Synagis coverage for the 2024-2025 RSV season
We would like to remind providers that Synagis requires prior authorization, and how to request authorization for the 2024-2025 season.
Coverage update for mental health wellness examinations
Mental health wellness examinations will now be covered annually at no cost to Tufts Health Together members, effective retroactively beginning July 1, 2024.
Pharmacy coverage changes
We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.
Behavioral health service navigation program for members
We recently launched our behavioral health service navigation program to provide personalized guidance for patients seeking information regarding telebehavioral health care.
Pharmacy coverage changes
We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.
ConnectorCare plans – in-network coverage reminder
Harvard Pilgrim has joined Tufts Health Plan as a ConnectorCare issuer for 2024, expanding access to affordable health care coverage for thousands of Massachusetts residents.
Coverage reminder – Community Behavioral Health Center services
We would like to remind providers of notification requirements and billing procedures related to Community Behavioral Health Center services.
Pharmacy coverage changes
We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.
Removal of prior authorization requirements for certain procedures
We are removing prior authorization requirements from certain procedures and associated codes in a continued effort to administratively simplify providers’ experience.
Pharmacy coverage changes
Read about updates to Point32Health’s Pharmacy program and our Pharmacy Medical Necessity Guidelines for Harvard Pilgrim and Tufts Health Plan.