Insights and Updates for Providers

October 2023

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

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.

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 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.

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.

Removing certain drugs from white-bagging program

Tufts Health Direct  |  Tufts Health Plan Commercial  |  Tufts Medicare Preferred

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

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

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

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

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.

Coverage updates for breastfeeding equipment and supplies

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

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.