Carelon molecular diagnostic testing program update
Our vendor partner for molecular diagnostic testing, Carelon, is implementing an update effective Aug. 1, 2025 regarding defining its service dates.
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.
Claims editing platform updates
In an effort to consistently apply industry standard claims edits reflecting national correct coding and guidelines from state regulatory agencies, we’re making updates to align our claims editing platforms.
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.
Pharmacy coverage changes
Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.
Initial inpatient admission notification requirement update
As of April 1, Point32Health must be notified within one business day following a member’s admission to an inpatient facility.
Enrollment/screening for RI Medicaid providers
If you are a RI Medicaid provider who hasn’t yet completed screening and enrollment with the state Medicaid program, please do so to ensure continued participation in our Tufts Health RITogether network.
Pharmacy coverage changes
Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.
Continued stay and inpatient level of care reviews
We’re sharing a reminder regarding continued stay reviews for DRG case rate admissions, and an update to our level of care review process for elective inpatient surgical procedures.
Prior authorization requirements for cardiac services
Effective for dates of service beginning March 1, 2025, Point32Health and Evolent are adding prior authorization requirements for a number of additional cardiac 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.
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.
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.
Rhode Island Medicaid rate updates
Point32Health is implementing reimbursement rate updates for Tufts Health RITogether providers, in accordance with recent direction from the Rhode Island EOHHS.
New community BH clinics program in RI
Rhode Island has recently designated several CCBHCs, which will be available to Tufts RITogether patients in need of specialized behavioral health care as of Oct. 1, 2024.
Enrollment/screening for RI Medicaid providers
Rhode Island Medicaid providers should complete screening and enrollment with the state Medicaid program to ensure continued participation in our Tufts Health RITogether network.
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.
RI Medicaid screening and prohibition of balance billing
Rhode Island Medicaid providers are required to complete screening and enrollment with Medicaid to receive payment for services for our Tufts Health RITogether members.
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.
Behavioral Health and substance use disorder tools and resources
Tufts Health RITogether behavioral health providers can use the resources listed to work with us and support patients with behavioral health care.
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.
Enrollment/screening for RI Medicaid providers
We would like to remind unscreened Rhode Island Medicaid providers to complete screening and enrollment with Rhode Island Medicaid as soon as possible.
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.
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.