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.
Insights and Updates for Providers
December 2023
Pharmacy coverage changes
Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.
Pharmacy program reminders
Coverage reminders related to our Pharmacy program.
Preferred oncology biosimilars for 2024
Preferred products for the bevacizumab, rituximab, and trastuzumab drug classes.
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.
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.
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.
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.
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.
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.
Requests for assisted reproductive technology services
We would like to provide some clarity regarding the correct processes for initiating prior authorization requests for assisted reproductive technology services for members of Harvard Pilgrim Health Care Commercial products, Tufts Health Plan Commercial products, and 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.
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.
Tufts Health Direct outpatient cost sharing updates
Effective Jan. 1, 2024, the following outpatient cost share updates will apply to Tufts Health Direct members:
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.