Massachusetts law states that the clinical review criteria used to establish a step therapy protocol cannot require members to utilize a medication that is not likely to be clinically effective for the prescribed purpose. Mandatory exceptions in step therapy protocols are now required.
Point32Health would like to remind providers of our policy regarding Synagis (palivizumab), an injection of antibodies used to protect high-risk infants from severe respiratory syncytial virus (RSV) disease, for the 2023-2024 season.
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.
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.
Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.
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.
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.
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.
Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.
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.
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.
Review this chart for updated Pharmacy Medical Necessity Guidelines with changes effective August 1, 2023 for Point32Health’s Pharmacy drug prior authorization 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.
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.
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.
As of Jan. 1, 2023, Point32Health provides coverage for breastfeeding supplies including storage bags for breast milk (HCPCS code K1005) for certain products, with a quantity limit of 300 bags per three-month reimbursement period.
Our comprehensive genomic profiling coverage, offered through FMI, has expanded.