MNG update: Non-Emergency Medical Transportation
Integrated Point32Health Medical Necessity Guidelines for Non-Emergency Medical Transportation.
Insights and Updates for Providers
April 2024
Standard form for Applied Behavior Analysis prior authorization requests
A standard authorization form for ABA services has been adopted.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Reminder: trastuzumab biosimilar strategy
Reminder of our biosimilar strategy for trastuzumab oncology drugs.
Individual Consideration Services Payment Policy
The Individual Consideration Services Payment Policy is being updated effective June 1.
Reminder: Step therapy protocols and exceptions
Massachusetts law now requires mandatory exceptions in step therapy protocols.
Coverage update for mental health wellness examinations
Annual mental health wellness exams covered at no cost for certain members.
Billing for lead screening
Lead screenings for ages 0-6 years covered with no member cost share.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Expanded access to CGP for advanced solid tumors
We’re reminding providers of our comprehensive genomic profiling coverage and authorization process.
Use code A4287 for coverage of breast milk storage bags
Use code A4287, not K1005, for coverage of breast milk storage bags.
Point32Health non-emergent ambulance reimbursement
Integrated Point32Health Ambulance and Transportation Services Payment Policy and reimbursement update.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Expanding our kidney health management program
Monogram Health program includes Tufts Health Direct members as of Jan. 1.
Pharmacy program reminders
Point32Health would like to offer some reminders pertaining to our Pharmacy program.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Pharmacy program reminders
Coverage reminders related to our Pharmacy program.
Urine Drug Testing Payment Policy integration
Urine Drug Testing coverage and payment policy updates.
Expanding our kidney health management program
Expanding Monogram Health kidney disease program to Tufts Health Direct.
Tufts Health Direct outpatient cost sharing updates
Effective Jan. 1, 2024, the following outpatient cost share updates will apply to Tufts Health Direct members:
New ICD-10 code for HIV PrEP
HIV PrEP billing requirements and new ICD-10 code.
Pharmacy coverage changes
Jan. 1, 2024 Pharmacy coverage changes for various Point32Health products.
Preferred oncology biosimilars for 2024
Preferred products for the bevacizumab, rituximab, and trastuzumab drug classes.
Other 2024 Pharmacy program updates
2024 Pharmacy updates: Harvard Pilgrim commercial, Tufts commercial, Tufts Health Direct.
Step Therapy Protocols and Exceptions
Learn more about mandatory exceptions in step therapy protocols.
Synagis coverage for the 2023-2024 RSV season
Point32Health would like to remind providers of our Synagis (palivizumab) policy for the 2023-2024 season.
Reminders and update: billing for PrEP and HIV services
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.
Pharmacy coverage changes
Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.
Reminder: prior authorization for long-acting opioids
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.
Pharmacy coverage changes
Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.
Prenatal vitamin coverage update
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
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
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.
AbleTo virtual behavioral health program expanded
AbleTo’s personalized therapy program is now available to Tufts Health Direct, Tufts Health Together-MCO, and Tufts Medicare Preferred members, and will continue to be offered to Harvard Pilgrim Health Care commercial and Stride (HMO/HMO-POS) Medicare Advantage members.
FDA-unapproved product coverage update
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.
Pharmacy coverage changes
Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.
Update for acute inpatient facility readmissions
Please be aware that for dates of service beginning Sept. 1, 2023, the readmission policies for DRG facilities for Tufts Health Direct, Tufts Health Together, and Tufts Health RITogether will be expanded to apply to providers reimbursed at a case rate.
Telehealth reimbursement for Tufts Health Direct members
As we announced in previous issues of Insights and Updates for Providers, Point32Health currently reimburses medical services provided via telehealth for our commercial Harvard Pilgrim Health Care and Tufts Health Plan members in Massachusetts, Rhode Island, and Maine at 80% of the in-person rate.
Pharmacy coverage changes
Review this chart for updated Pharmacy Medical Necessity Guidelines with changes effective August 1, 2023 for Point32Health’s Pharmacy drug prior authorization program.
Removing certain drugs from white-bagging program
Effective for dates of service beginning July 1, 2023, the medications identified in this article will no longer be offered through CVS Caremark as part of Tufts Health Plan’s office-administered medical drug/white bagging program.
Reimbursement update for IEP services effective July 1
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.
Behavioral Health Medical Necessity Guideline updates
We’re updating our Medical Necessity Guidelines for the behavioral health services Transcranial Magnetic Stimulation, Psychological Testing and Assessment, and Neuropsychological Testing and Assessment, effective for dates of service beginning July 1, 2023.