Effective for dates of service beginning April 1, 2023 for members of Harvard Pilgrim’s Commercial and StrideSM (HMO)/(HMO-POS) plans, oral enteral formulas must be obtained through a contracted durable medical equipment (DME) provider, rather than at a retail pharmacy in order for them to be covered — similar to Tufts Health Plan’s current policy. Oral formulas currently require prior authorization for these Harvard Pilgrim members and will continue to do so.
Member cost share for medical supplies applies to each supply of oral enteral formula dispensed by a DME supplier. Ordering providers should send a formula prescription to a Harvard Pilgrim-contracted DME formula supplier, who will in turn submit the prior authorization request to Harvard Pilgrim.
For information on in-network contracted DME providers, refer to the Harvard Pilgrim Provider Directory.
Updates to oral formula policies
In conjunction with this change, also effective April 1, 2023, we are integrating and updating our formulas and enteral nutrition medical necessity guidelines for members of our Commercial products, Tufts Health Direct, and Harvard Pilgrim Medicare Advantage. Changes include the following.
Commercial members (both Harvard Pilgrim and Tufts Health Plan) and Tufts Health Direct
Relizorb, a digestive enzyme cartridge (B4105–In-line cartridge containing digestive enzymes for enteral feeding, each), will be covered with prior authorization for Commercial Harvard Pilgrim members and Commercial Tufts Health Plan members with cystic fibrosis who require formulas.
Changes applicable to Tufts Health Plan Commercial products and Tufts Health Direct
Prior authorization will be required for tube administration of formulas.
Changes applicable to Harvard Pilgrim
- Criteria was updated to include more detailed information about covered indications for oral administration
- Criteria for tube administration was streamlined, with coverage indicated when:
- Formula provides 50% of the member’s nutritional intake
- Member has a contraindication to oral administration of formula
- Treating physician prescribed tube administration and is supervising the member’s treatment
In addition, please note the following reminders for Harvard Pilgrim members:
- As a reminder, the supply codes B4034, B4035, and B4036 require prior authorization
- Tube administration requires prior authorization
For further details, please refer to the Harvard Pilgrim Oral Formula and Enteral Nutrition Medical Necessity Guidelines and Durable Medical Equipment Payment Policy.
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