GLP-1 weight management medication coverage changes
Point32Health is making changes related to coverage of GLP-1 weight management medications, and will be designating Zepbound as the preferred product as of July 1, 2025.
Insights and Updates for Providers
May 2025
Pharmacy coverage changes
Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.
GLP-1 weight management medication coverage changes
Point32Health is making changes related to coverage of GLP-1 weight management medications, as part of our efforts to provide access to the most appropriate and efficacious health care options while managing health care costs.
Prior authorization reminder: intensity-modulated radiation therapy
As a reminder, as of April 1 the previously announced continuity of care period has ended and a prior authorization must be obtained for all members starting IMRT prior to their course of treatment.
Pharmacy coverage changes
Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.
Commercial migration reminder: avoid duplicate claims
When submitting claims for members who have switched plans, please remember to submit claims to the health plan based on the member’s eligibility on the date of service.
Pharmacy split fill program for select oral oncology drugs
Point32Health is implementing a pharmacy split fill program for select oncology drugs to improve medication adherence and reduce drug wastage.
Pharmacy coverage changes
Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.
Fee schedule updates in effect April 1
Updates to our Harvard Pilgrim Health Care Commercial professional fee schedules and our Point32Health behavioral health fee schedule will take effect on April 1, 2025.
Pharmacy coverage changes
Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.
Insourcing chronic kidney disease care management
Point32Health will be insourcing chronic kidney disease (CKD) care management services for Harvard Pilgrim Health Care and Tufts Health Plan Commercial members beginning Jan. 1, 2025.
PPACA coverage policy updates for 2025
We’ve made minor updates to the Harvard Pilgrim Patient Protection and Affordable Care Act Policy, and we’ve developed equivalent policies for Tufts Health Plan Commercial and Direct.
Coverage for inpatient donor human milk
As of Nov. 21, 2024, Point32Health will now cover medically necessary inpatient donor human milk and donor human milk-derived products for members of certain Massachusetts plans.
Pharmacy coverage changes
We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.
Billing for behavioral health boarding
We’ve clarified the billing requirements outlined in our payment policies pertaining to BH boarding, and have updated a BH boarding billing requirement for Tufts Health Direct.
Observation Stay Payment Policy and process change
Effective Jan. 1, 2025, Point32Health is making a change to our review process for short inpatient stays and observation services.
Pharmacy coverage changes
The following changes to Point32Health’s Pharmacy program take effect on Jan. 1, 2025, including prior authorization, drug status, and formulary updates for various products.
Removing certain drugs from white bagging program
Effective for dates of service beginning Jan. 1, 2025, certain medications will be removed from the Office-Administered Medical Drugs list.
Other 2025 Pharmacy program updates
We are providing pharmacy updates for the 2025 plan year regarding formularies, weight loss prescription drugs and diabetic GLP-1 coverage, and adalimumab.
2025 medical benefit step therapy program
The chart in this article outlines a new medical benefit step therapy program, which will be effective for fill dates on or after Jan. 1, 2025.
Expansion of cryopreservation and storage coverage
Our cryopreservation and storage benefit now includes coverage for ovarian tissue and testicular tissue, in addition to the previous coverage for sperm, eggs, and embryos.
Clinical documentation required for radiology services
As of Jan. 1, Point32Health will require clinical documentation for outpatient advanced imaging services for Tufts Health Plan Commercial and Tufts Health Public Plans members.
New Point32Health webpages to streamline your operations
We are announcing a few integrated webpages to streamline the provider experience, including our Prior Authorization, Forms, and Vendor Programs pages.
Electronic corrected claims reminder
As a reminder, corrected claims submissions should not include documentation of previous payment information, as this may delay processing.
Synagis coverage for the 2024-2025 RSV season
We would like to remind providers that Synagis requires prior authorization, and how to request authorization for the 2024-2025 season.
Payment Policy update and modifier requirements
We’re introducing a streamlined Point32Health Drugs and Biologicals Payment Policy and will require providers to append modifier JW or JZ, when applicable.
Coverage update for mental health wellness examinations
Mental health wellness examinations will now be covered annually at no cost to Tufts Health Together members, effective retroactively beginning July 1, 2024.
Psychotherapy services billing reminder
When billing for psychotherapy services, use the procedure code that most closely reflects the duration of time spent with the patient during the session.
Pharmacy coverage changes
We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.
Prior authorization required for noninvasive prenatal testing
Point32Health requires prior authorization for coverage of all prenatal testing, including NIPT, which can be requested using the resources provided here.
Behavioral health service navigation program for members
We recently launched our behavioral health service navigation program to provide personalized guidance for patients seeking information regarding telebehavioral health care.
Pharmacy coverage changes
We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.
Change Healthcare update: Timely filing limits and claim adjustment requirements to resume
Point32Health will return to our standard requirements for all lines of business regarding timely filing and claim adjustments, effective Sept. 1, 2024.
Recovering negative balances
We have outlined reasons why a claim may be retracted, resulting in a negative balance, and ways to resolve a negative balance.
Reminder: removal of certain prior authorization requirements
We would like to remind our providers of certain procedures and associated codes that no longer require prior authorization.
Coverage reminder – Community Behavioral Health Center services
We would like to remind providers of notification requirements and billing procedures related to Community Behavioral Health Center services.
Pharmacy coverage changes
We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.
Removal of prior authorization requirements for certain procedures
We are removing prior authorization requirements from certain procedures and associated codes in a continued effort to administratively simplify providers’ experience.
Pharmacy coverage changes
Read about updates to Point32Health’s Pharmacy program and our Pharmacy Medical Necessity Guidelines for Harvard Pilgrim and Tufts Health Plan.