Insights and Updates for Providers

June 2024

Removal of prior authorization requirements for certain procedures

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

We are removing prior authorization requirements from certain procedures and associated codes in a continued effort to administratively simplify providers’ experience.

Pharmacy coverage changes

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

Read about updates to Point32Health’s Pharmacy program and our Pharmacy Medical Necessity Guidelines for Harvard Pilgrim and Tufts Health Plan.

Reminder: required billing for telehealth services

Harvard Pilgrim Health Care Commercial | Tufts Health Direct | Tufts Health One Care | Tufts Health Plan Commercial | Tufts Health Plan Senior Care Options | Tufts Health RITogether | Tufts Health Together | Tufts Medicare Preferred HMO/PPO

Please keep required billing practices for telehealth services in mind.

Pharmacy coverage changes

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

Pharmacy coverage changes for various Point32Health products.

MNG update: Non-Emergency Medical Transportation

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

Integrated Point32Health Medical Necessity Guidelines for Non-Emergency Medical Transportation.

Pharmacy coverage changes

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

Pharmacy coverage changes for various Point32Health products.

Reminder: trastuzumab biosimilar strategy

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

Reminder of our biosimilar strategy for trastuzumab oncology drugs.

Billing for lead screening

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

Lead screenings for ages 0-6 years covered with no member cost share.

Pharmacy coverage changes

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

Pharmacy coverage changes for various Point32Health products.

Expanded access to CGP for advanced solid tumors

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

We’re reminding providers of our comprehensive genomic profiling coverage and authorization process.

Point32Health non-emergent ambulance reimbursement

Harvard Pilgrim and Tufts Commercial | Tufts Health Direct | Tufts Health One Care | Tufts Health Plan Commercial | Tufts Health Plan SCO | Tufts Health RITogether | Tufts Health Together | Tufts Medicare Preferred

Integrated Point32Health Ambulance and Transportation Services Payment Policy and reimbursement update.

Pharmacy coverage changes

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

Pharmacy coverage changes for various Point32Health products.

Pharmacy program reminders

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

Point32Health would like to offer some reminders pertaining to our Pharmacy program.

Pharmacy coverage changes

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

Pharmacy coverage changes for various Point32Health products.

Pharmacy coverage changes

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

Pharmacy coverage changes for various Point32Health products.

Pharmacy program reminders

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

Coverage reminders related to our Pharmacy program.

New ICD-10 code for HIV PrEP

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

HIV PrEP billing requirements and new ICD-10 code.

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.

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

Learn more about mandatory exceptions in step therapy protocols.

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.

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.

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.

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.

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.

AbleTo virtual behavioral health program expanded

Tufts Health Direct | Tufts Health Together—MCOs | Tufts Medicare Preferred

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

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.

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.

Update for acute inpatient facility readmissions

Tufts Health Direct | Tufts Health RITogether | Tufts Health Together | Uncategorized

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

Tufts Health Direct

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

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

Review this chart for updated Pharmacy Medical Necessity Guidelines with changes effective August 1, 2023 for Point32Health’s Pharmacy drug prior authorization program.